Peptides, derivatives and analogs thereof, and methods of using same

ABSTRACT

Human proIslet Peptides (HIP) and HIP analogs and derivatives thereof, derived from or homologous in sequence to the human REG3A protein, chromosome 2p12, are able to induce islet neogenesis from endogenous pancreatic progenitor cells. Human proIslet Peptides are used either alone or in combination with other pharmaceuticals in the treatment of type 1 and type 2 diabetes and other pathologies related to aberrant glucose, carbohydrate, andor lipid metabolism, insulin resistance, overweight, obesity, polycystic ovarian syndrome, eating disorders and the metabolic syndrome.

CROSS REFERENCE TO RELATED APPLICATIONS

This application is a continuation application of pending U.S.application Ser. No. 13745,706, filed Jan. 18, 2013, which is acontinuation of U.S. application Ser. No. 13168,461, filed Jun. 24,2011, now U.S. Pat. No. 8,383,578, which is a continuation applicationof U.S. application Ser. No. 12635,053, filed Dec. 10, 2009, now U.S.Pat. No. 7,989,415, dated Aug. 2, 2011, which is a divisionalapplication of U.S. application Ser. No. 12121,123 filed on May 15,2008, now U.S. Pat. No. 7,714,103, dated May 11, 2010, which is acontinuation application of U.S. application Ser. No. 11441,491 filed onMay 25, 2006, now U.S. Pat. No. 7,393,919, dated Jul. 1, 2008, whichclaims the benefit of U.S. Provisional Application No. 60684,819, filedon May 25, 2005; all aforementioned applications are herein incorporatedby reference in their entirety.

REFERENCE TO GOVERNMENT GRANT

Not Applicable

JOINT RESEARCH AGREEMENT

Not Applicable

FIELD OF THE INVENTION

The present invention provides peptides and analogs thereof and methodsof using them for treating type 1 diabetes mellitus, type 2 diabetesmellitus and other conditions. The invention relates to the fields ofmolecular biology, biology, chemistry, medicinal chemistry, andpharmacology.

BACKGROUND OF THE INVENTION

Since 1922, insulin has been the only available therapy for thetreatment of type 1 diabetes and other conditions related to the lack ofor diminished efficacy or production of insulin. However, diabeticpatients on insulin do not have normal glucose metabolism, becauseinsulin is only part of the missing and aberrant pancreatic function.Despite decades of research and the advent of pancreatic islettransplantation in 1974 and newer claims of success resulting from theEdmonton Protocol for islet transplantation, these approaches have notbeen very successful in the United States. For example, at four yearspost-transplant, fewer than 10% of patients who have received islettransplants remain insulin independent. Additionally, there is an 18%rate of serious side effects.

Investigators have also researched whether endogenous production ofinsulin can be stimulated by drug treatment. For example, over the pastseveral decades, several therapies have been studied which are involvedin glucose metabolism, and analogs of these peptides have beenidentified. These therapies include sequences which are similar toGlucagon Like Peptide-1 (GLP-1) and include: GLP-1 receptor analogs,Exendin-4, ExenatideBYETTA™, which is derived from the Gila Monster,Gastric Inhibitory PeptideGlucose-Dependent Insulinoptropic polypeptide(GIP), and compounds homologous to GLP-1, such as Liraglutide (NN2211),Dipeptidyl Peptidase-4 Inhibitors, which inhibit the breakdown of GLP-1,Gastrin, Epidermal Growth Factor and Epidermal Growth Factor Analogs,and Hamster derived Islet Neogenesis Associated Peptide (INGAP).

More specifically, hamster INGAP fragments have been identified (seeRonit, R, et al. Journal of Clinical Investigation May 1997, vol 99 (9):2100-2109; U.S. Pat. No. 5,834,590; and U.S. Patent ApplicationPublication No. 20040132644). Hamster-derived INGAP may be effective infacilitating pancreatic islet neogenesis. However, INGAP is not a humanpeptide, and thus may not be as efficacious and could produce an adverseimmune response in some subjects.

Proof of the elasticity of the pancreas with respect to the generationof new pancreatic islets throughout one's lifetime accompanied bypancreatic islet death or apoptosis has replaced the long held conceptthat the number of insulin producing islet structures is fixed at birthand maintained throughout life, whereas the plasticity and ability ofbeta cells to proliferate within existing islets has been wellestablished. It is currently accepted that pancreatic islet neogenesisoccurs from preexisting pancreatic cells through differentiation ofprogenitor cells found amongst both the endocrine and exocrine fractionsof the pancreas. Data demonstrates that, even decades after the onset oftype 1 diabetes, insulin producing islets can be regenerated. Forexample, patients with type 1 diabetes who can make normal levels ofC-peptide during pregnancy. Several teams have found a paradoxical risein C-peptide levels during the first trimester of pregnancy into thenormal range in as many as one-third of all pregnant type 1 patients(Lewis et al., 1976, Rigg et al., 1980, Ilic et al., 2000, Jovanovic etal., 2001). This rise in C-peptide is accompanied by a significantreduction in insulin requirements with some patients being able tocompletely discontinue insulin transiently during the first trimester ofpregnancy. This rise in C-peptide during pregnancy that occurs within 10weeks of gestation among patients, despite no measurable C-peptide priorto pregnancy, implies the restoration of functioning islet structures.It is hypothesized that the islet neogenesis that occurs duringpregnancy results from the concomitant rise in endogenous steroidproduction and a down regulation of the immune system preventing immuneattack on the fetus, which likely also plays a role in suppression oflymphocyte attack on the islets. Along with immune suppression, it isalso speculated that there is an up regulation of maternal islet growthpromoting factors during pregnancy to compensate for the lowering of thematernal glucose setpoint in pregnancy. Similarly, patients who havebeen on long term immunosuppression for kidney transplantation have beenobserved to regenerate insulin producing islets.

Over the past decade, clinical trials have been conducted to evaluatethe impact of a number of immune modulators that may arrest thedestruction of the beta cells of the pancreas. Anti CD-3 antibodies(hOKT3γ1(Ala-Ala and ChAglyCD3) that target the immune response andspecifically block the T-lymphocytes that cause beta cell death in type1 diabetes have been utilized, as have, Sirolimus (Rapamycin),Tacrolimus (FK506), a heat-shock protein 60 (DIAPEP277™) ananti-Glutamic Acid Decarboxylase 65 (GAD65) vaccine, MycophenolateMofetil alone or in combination with Daclizumab, the anti-CD20 agent,lysofylline, Rituximab, Campath-1H (Anti-CD52 Antibody) and Vitamin D,IBC-VSO vaccine which is a synthetic, metabolically inactive form ofinsulin designed to prevent pancreatic beta-cell destruction,interferon-α vaccination using CD4⁺CD25⁺ antigen-specific regulatory Tcells or a similar agent is used in the combination therapy approachesto utilizing regulatory T cells either directly or through the use ofimmunotherapy to arrest the destruction of insulin-producing cells. Theaim of these trials is to determine the ability of such agents topreserve islet function by preventing further immune attack on the betacells of the islets of the pancreas.

Additionally, recent studies have found that vitamin D may play animportant immune modulating role in the prevention of type 1 diabetes.Up to 54.7% of populations in the US, regardless of latitude, have low25 hydroxyvitamin D levels (Holick, J Clin Endorinol Metab 2005;90-3215-3224). Vitamin D deficiency has been demonstrated, not only tobe associated with the increased risk of type 1 diabetes and seen at theonset of type 1 diagnosis, but also is commonly seen among both patientswith type 1 and 2 diabetes. Maintaining levels above 40 ngml arerecommended to sustain normal immune function (Riachy Apoptosis. 2006February; 11(2):151-9. Holick. Mayo Clin Proc. 2006 March; 81(3):353-73,Grant. Prog Biophys Mol Biol. 2006 Feb. 28; [Epub ahead of print].DiCesar. Diabetes Care. 2006 January; 29(1):174, Reis. Diabetes Metab.2005; 31(4 Pt 1):318-25, Pozzilli. Horm Metab Res. 2005; 37(11):680-3).No adverse effects have been seen with dosages up to 10,000 IUday(Heaney. Am J Clin Nutr, 204-210, Vieth. Am J Clin Nutr. 2001;73:288-294).

To date, however, there has been no single or combination therapy thathas been successfully used to treat the underlying disease mechanisms oftype 1 diabetes, type 2 diabetes or conditions in which there is a lackof or diminished insulin production andor alterations in glucosemetabolism or insulin secretion, including obesity, overweight, insulinresistant syndromes and the metabolic syndrome. There remains a need fornew treatments methods and pharmaceutical compositions, which addressthe underlying mechanisms for the alterations in type 1 diabetesmellitus, type 2 diabetes mellitus and conditions in which there is analteration in insulin secretion. Especially needed are methods andcompositions that can also treat the many other conditions in which thelack of, or diminished, insulin production has a causative role orcontributes to the symptoms of patients in need of treatment. Atpresent, there appears to be no treatment that ameliorates the symptomsof type 1 diabetes by targeting the mechanisms underlying all of thesedisease states. The present invention meets the need for improvedtherapies for treating type 1 diabetes, type 2 diabetes and otherconditions.

SUMMARY OF THE INVENTION

The invention provides a Human proIslet Peptide (HIP) or an analog or aderivative thereof comprising the amino acid sequence of SEQ ID NO:13.In one embodiment of the HIP or an analog or a derivative thereof, theHIP or an analog or a derivative thereof is less than 17 amino acids inlength. In one aspect of this embodiment of the invention, HIP or ananalog or a derivative thereof comprises an amino acid sequence selectedfrom a member of the group consisting of SEQ ID NOs:2, 3, 4, 5, 6, 7, 18and 19. The invention also provides pharmaceutical preparationscomprising the HIP or an analog or derivative together with apharmaceutically acceptable excipient.

The invention also provides a method of treating a pathology associatedwith impaired pancreatic function in a subject in need of suchtreatment. The method is practiced by administering to the patient atherapeutic amount of one or more Human proIslet Peptides or analogs orderivatives thereof, thereby treating type 1 or type 2 diabetes in thesubject. In one embodiment of the method of treating type 1 or type 2diabetes, the Human proIslet Peptide comprises an amino acid sequenceselected from a member of the group consisting of SEQ ID NOs:2, 3, 4, 5,6, 7, 18 and 19. In one aspect of this embodiment, the Human proIsletPeptide is 17 amino acids in length or less.

In another embodiment of the method of treating a pathology associatedwith impaired pancreatic function in a subject in need of suchtreatment, the method further comprises the step of administering one ormore agents for stimulating pancreatic islet cell regeneration. In oneaspect of this embodiment, the agents are selected from a member of thegroup consisting of Human proIslet Peptide, amylinPramlintide (SYMLIN™),exendin-4 (EXENATIDE™), GIP, GLP-1, GLP-1 receptor agonists, GLP-1analogs, hamster INGAP, Liraglutide (NN2211) or a dipeptidyl peptidaseinhibitor, which blocks the degradation of GLP-1.

In another embodiment of the method of treating a pathology associatedwith impaired pancreatic function in a subject in need of suchtreatment, the method further comprises the steps of 1) intensifyingglycemic control 2) the addition of oral vitamin D3 (cholecalciferol) tomaintain 25-hydroxyvitamin levels above 40 ngml 3) the addition of oneor more immune therapies for protecting new islet cell formation 4)administration of HIP or HIP analogs for stimulating pancreatic isletcell regeneration, while tapering off insulin 5) repeated therapy forprotection of islets on a 3 to 24 month basis, dependent on the selectedimmune therapy and 6) Maintainence of 25-hydroxyvitamin D levels above40 ngml with oral vitamin D3 (cholecalciferol).

In another embodiment of the method of treating a pathology associatedwith impaired pancreatic function in a subject in need of suchtreatment, the method further comprises the steps which may include: 1)intensifying glycemic control 2) the addition of vitamin(cholecalciferol) to maintain 25-hydroxyvitamin levels above 40 ngml 3)administration of an agent for stimulating pancreatic islet regenerationincluding the administration of HIP or HIP analogs 4) Co-administrationof a member of the group consisting of amylinPramlintide (SYMLIN™),exendin-4 (EXENATIDE™), GIP, GLP-1, GLP-1 receptor agonists, GLP-1analogs, INGAP, Liraglutide (NN2211) or a dipeptidyl peptidaseinhibitor, which blocks the degradation of GLP-1, while tapering offdiabetes therapy and 5) maintaining levels of 25-hydroxy vitamin D above40 ngml with oral Vitamin D3 (cholecalciferol).

In one aspect of this embodiment, the agents for stimulating pancreaticislet or beta cell regeneration are selected from a member of the groupconsisting of HIP and HIP analogs, exendin-4 (EXENATIDEBYETTA™),Gastrin, Epidermal Growth Factor and Epidermal Growth Factor analog,GIP, GLP-1, GLP-1 receptor agonists, GLP-1 analogs, INGAP, Liraglutide(NN2211) andor Dipeptidyl Peptidase 4 Inhibitors.

In another embodiment of the method of treating a pathology associatedwith impaired pancreatic function in a subject in need of suchtreatment, the method further comprises the step of administering one ormore agents that inhibit, block, or destroy the autoimmune cells thattarget pancreatic islets. In one aspect of this embodiment, the agentsthat inhibit, block, or destroy the autoimmune cells that targetpancreatic islets are selected from the group consisting of Anti CD-3antibodies (hOKT3γ1(Ala-Ala and ChAglyCD3) that target the immuneresponse and specifically block the T-lymphocytes that cause beta celldeath in type 1 diabetes, as well as, Sirolimus (Rapamycin), Tacrolimus(FK506), a heat-shock protein 60 (Diapep277) an anti-Glutamic AcidDecarboxylase 65 (GAD65) vaccine, Mycophenolate Mofetil alone or incombination with Daclizumab, the anti-CD20 agent, Rituximab, Campath-1H(Anti-CD52 Antibody), lysofylline, Vitamin D, IBC-VSO vaccine which is asynthetic, metabolically inactive form of insulin designed to preventpancreatic beta-cell destruction, interferon-alpha, vaccination usingCD4⁺CD25⁺ antigen-specific regulatory T cells or a similar agent is usedin the combination therapy approaches to utilizing regulatory T cellseither directly or through the use of immunotherapy to arrest thedestruction of insulin-producing cells.

In another embodiment of the method of treating a pathology associatedwith impaired pancreatic function in a subject in need of suchtreatment, at least one symptom of the pathology associated withimpaired pancreatic function is treated or reduced as a result of theadministration of at least one Human proIslet Peptide. In one aspect ofthis embodiment, the symptom is selected from a member of the groupconsisting of low levels of insulin or insulin activity, insulinresistance, hyperglycemia, hemoglobin A1C level greater than 6.0%,frequent urination, excessive thirst, extreme hunger, unusual weightloss or gain, being overweight, increased fatigue, irritability, blurryvision, genital itching, odd aches and pains, dry mouth, dry or itchyskin, impotence, vaginal yeast infections, poor healing of cuts andscrapes, excessive or unusual infections, loss or worsening of glycemiccontrol, fluctuations in blood glucose, fluctuations in blood glucagon,and fluctuations in blood triglycerides, with hyperglycemia ultimatelyleading to microvascular and macrovascular complications, which includevisual symptoms that lead to blindness, accelerated kidney impairmentthat can lead to renal failure necessitating dialysis or kidneytransplant and neuropathy leading to foot ulcers and amputations.Additionally, recent studies have demonstrated both microvascular andmacrovascularcardiovascular risk reduction among type 1 diabetespatients who have improved glycemic control.

In another embodiment of the method of treating a pathology associatedwith impaired pancreatic function in a subject in need of suchtreatment, the pathology associated with impaired pancreatic function isany one of type 1 diabetes, new onset type 1 diabetes, type 2 diabetes,latent autoimmune diabetes of adulthood, pre-diabetes, impaired fastingglucose, impaired glucose tolerance, insulin resistant syndrome,metabolic syndrome, being overweight, obesity, hyperlipidemia,hypertriglyceridemia, eating disorders and polycystic ovarian syndrome.

The invention also provides an antibody which selectively binds to a HIPor analog or derivative thereof comprising an amino acid sequenceselected from a member of the group consisting of SEQ ID NOs:2, 3, 4, 5,6, 7, 18 and 19. In one embodiment, the antibody is a monoclonalantibody. In another embodiment, the antibody is a polyclonal antibody.Such antibodies can be used in diagnostic methods provided by theinvention, which methods comprise detecting HIP or analog or derivativelevels in the serum or tissue of a mammal in one embodiment, suchmethods are used to diagnose a disease or condition related to aberrantHIP levels; in another embodiment, the diagnostic method is used tomonitor treatment with HIP or an analog or derivative to ensure thattherapeutically effective levels are being achieved in a patientreceiving such therapy.

The invention also provides a kit for treating a patient having type 1or type 2 diabetes or other condition in which there are aberrantinsulin levels, perturbation in glucose metabolism or insulinresistance, comprising a therapeutically effective dose of a HumanproIslet Peptide and optionally at least one agent for stimulating GLP-1receptors or enhancing GLP-1 levels, promoting beta cell regeneration,increased satiety, decreased food intake and weight loss, while reducingneeds for insulin and other diabetic agents either in the same orseparate packaging, and instructions for its use. The invention alsoprovides a kit for measuring HIP levels in a sample, the kit comprisinga HIP-specific antibody and optionally HIP and optionally a labelingmeans.

These and other aspects and embodiments of the invention are describedin greater detail below.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a bar graph showing increased insulin production in humanpancreatic ductal tissue culture after treatment with 3.3 μM (finalculture concentration of 165 nM) HIP1 (SEQ ID NO:7), HIP2 (SEQ ID NO:3),and HIP3 (SEQ ID NO:2), as compared with similar treatment with INGAPpeptide and a scrambled negative control.

FIG. 2 is a bar graph showing increased insulin production in humanpancreatic islet tissue after treatment with 1 mM for a final cultureconcentration of 500 nM HIP1 (SEQ ID NO:7), HIP2 (SEQ ID NO:3), and HIP3(SEQ ID NO:2), as compared with similar treatment with INGAP peptide anda scrambled negative control.

FIGS. 3A-3E. FIG. 3A shows a micrograph of a pancreatic ductal tissuefraction culture after six days of culture with HIP, (SEQ ID NO:2). Newislet structure has formed within the cell culture. FIG. 3B shows amicrograph of a pancreatic ductal tissue fraction culture after culturewith HIP, (SEQ ID NO:2). New islet structure has formed within the cellculture. FIG. 3C shows a micrograph of a pancreatic ductal tissuefraction culture after culture with HIP, (SEQ ID NO:2). New isletstructure has formed within the cell culture. FIG. 3D shows a micrographof a pancreatic ductal tissue fraction culture without culture with HIP,(SEQ ID NO:2). FIG. 3E shows a micrograph of a higher magnificationmicrograph of the micrograph shown in FIG. 3A.

FIG. 4 is a bar graph showing increased insulin production in humanpancreatic ductal tissue cultures treated with HIP peptides after 10days according to Rosenberg protocol. Peptides 1, 2, 3 are HIP analogsSEQ ID 7, SEQ ID 3, and SEQ ID 2, as compared with similar treatmentwith Peptide 4 (the hamster INGAP sequence) and Peptide 5, a scramblednegative control. Samples are 5 μg total protein in duplicate andmeasured by ELISA assay.

FIG. 5 is a bar graph showing increased insulin production in humanpancreatic islet tissue cultures treated with HIP peptides after 10 daysaccording to Rosenberg protocol. HIP1, 2 and 3 are HIP analogs SEQ IDNO:7, SEQ ID NO:3, and SEQ ID NO:2, as compared with similar treatmentwith Peptide 4 (the hamster INGAP sequence) and Peptide 5, a scramblednegative control. Samples 0.002 μg total protein in duplicate andmeasured by ELISA assay.

FIGS. 6A and 6B. FIG. 6A is an inverted micrograph showing humanpancreatic progenitor cells, forming a nidus of new insulin producingislets after two days of treatment with HIP. FIG. 6B is an invertedmicrograph showing human pancreatic progenitor cells forming insulinproducing islet like structure after six days of treatment with HIP.

FIGS. 7A and 7B. FIG. 7A is a bar graph showing increased insulinproduction in human pancreatic ductal tissue cultures treated with twoconcentrations of HIP peptides. HIP1, 2 and 3 are HIP analogs SEQ IDNO:7, SEQ ID NO:3, and SEQ ID NO:2, as compared with similar treatmentwith Peptide 4 (the hamster INGAP sequence) and Peptide 5, a scramblednegative control. Values are mean insulin units (of duplicate samples)as measured by ELISA assay. FIG. 7B is a bar graph showing increasedinsulin production in human pancreatic islet tissue cultures treatedwith two concentrations of HIP peptides. HIP1, 2 and 3 are HIP analogsSEQ ID NO:7, SEQ ID NO:3, and SEQ ID NO:2, as compared with similartreatment with Peptide 4 (the hamster INGAP sequence) and Peptide 5, ascrambled negative control. Values are mean insulin units (of duplicatesamples) as measured by ELISA assay.

DETAILED DESCRIPTION OF THE INVENTION

The invention provides Human proIslet Peptides (HIP) and analogs andderivatives thereof. Human proIslet Peptides are active fragments of thehuman protein regenerating islet-derived 3 alpha protein (REG3A)(NM_(—)138937.1), also known as pancreatitis-associated proteinprecursor (NP_(—)002571), incorporated herein by reference, located onchromosome 2p12. HIP induces or stimulates islet neogenesis fromprogenitor cells resident within the pancreas. This neogenesis agent isused to treat diseases associated with low or inadequate levels ofinsulin or insulin activity resulting in aberrant carbohydratemetabolism which may result from pancreatic islet dysfunction or immunedestruction such as diabetes mellitus (type 1 diabetes), type 2 diabetes(non-insulin dependent diabetes mellitus and insulin requiring adultonset diabetes, diabetes in childhood and adolescence) or LatentAutoimmune Diabetes in Adults (LADA).

The invention also provides pharmaceutical compositions and therapiesfor the treatment of pancreatic dysfunction including type 1 and type 2diabetes. In one embodiment, these compositions comprise HIP or ananalog or derivative. In another embodiment, these compositions includeHIP and other compositions that affects glucose metabolism. Includedamong these other compositions are agents that are involved inpancreatic islet neogenesis and agents that inhibit, block, or destroythe autoimmune cells that target pancreatic islet cells. In oneembodiment, the therapies of the invention are practiced byadministering a therapeutically effective dose of HIP or an analog orderivative to a mammal in need of such therapy. In another embodiment,the therapies of the invention are practiced by administering atherapeutically effective dose of HIP or an analog or derivative to amammal in need of such therapy in combination with another hormone orcompound that affects glucose metabolism, including but not limited tohormones or compounds that are involved in beta cell regeneration,satiety, and gastric emptying, such as GLP-1, GIP, GLP-1 receptoranalogs, GLP-1 analogs, and Dipeptidyl Peptidase-4 Inhibitors whichprevent destruction of GLP-1 and agents that inhibit, block, or destroythe autoimmune cells that target pancreatic cells. In this latterembodiment, the HIP or analog or derivative and the other hormone oragent may be administered separately or may first be admixed to providea combination composition of the invention and administeredsimultaneously.

DEFINITIONS

The following definitions are provided to assist the reader. Unlessotherwise defined, all terms of art, notations and other scientific ormedical terms or terminology used herein are intended to have themeanings commonly understood by those of skill in the chemical andmedical arts. In some cases, terms with commonly understood meanings aredefined herein for clarity andor for ready reference, and the inclusionof such definitions herein should not necessarily be construed torepresent a substantial difference over the definition of the term asgenerally understood in the art.

As used herein, “treating” a condition or patient refers to taking stepsto obtain beneficial or desired results, including clinical results. Forpurposes of this invention, beneficial or desired clinical resultsinclude, but are not limited to, alleviation or amelioration of one ormore symptoms of diabetes, diminishment of extent of disease, delay orslowing of disease progression, amelioration, palliation orstabilization of the disease state, and other beneficial resultsdescribed below. Symptoms of diabetes include low or inadequate levelsof insulin or insulin activity, frequent urination, excessive thirst,extreme hunger, unusual weight loss, increased fatigue, irritability,blurry vision, genital itching, odd aches and pains, dry mouth, dry oritchy skin, impotence, vaginal yeast infections, poor healing of cutsand scrapes, excessive or unusual infections, hyperglycemia, loss ofglycemic control, fluctuations in postprandial blood glucose,fluctuations in blood glucagon, fluctuations in blood triglycerides.Diabetes may be diagnosed by methods well known to one of ordinary skillin the art. For example, commonly, diabetics have a plasma blood glucoseresult of greater than 126 mgdL of glucose. Pre diabetes, which may alsobe treated by the compositions and methods of the invention is commonlydiagnosed in patients with a blood glucose result between 100 and 125mgdL of glucose. Other symptoms may also be used to diagnose diabetes,related diseases and conditions, and diseases and conditions affected bydiminished pancreatic function.

As used herein, “reduction” of a symptom or symptoms (and grammaticalequivalents of this phrase) means decreasing of the severity orfrequency of the symptom(s), or elimination of the symptom(s).

As used herein, a “pathology associated with impaired pancreaticfunction” is one in which the pathology is associated with a diminishedcapacity in a subject for the pancreas of the subject to produce andorsecrete hormones andor cytokines. Preferably this hormone or cytokine isinsulin. Pathologies that are associated with impaired pancreaticfunction include type 1 diabetes, new onset type 1 diabetes, type 2diabetes, latent autoimmune diabetes of adulthood, pre-diabetes,impaired fasting glucose, impaired glucose tolerance, insulin resistantsyndrome, metabolic syndrome, being overweight, obesity, hyperlipidemia,hypertriglyceridemia, eating disorders and polycystic ovarian syndrome.

As used herein, “administering” or “administration of” a drug to asubject (and grammatical equivalents of this phrase) includes bothdirect administration, including self-administration, and indirectadministration, including the act of prescribing a drug. For example, asused herein, a physician who instructs a patient to self-administer adrug andor provides a patient with a prescription for a drug isadministering the drug to the patient.

As used herein, a “subject” or “patient” is a mammal, typically a human,but optionally a mammalian animal of veterinary importance, includingbut not limited to horses, cattle, sheep, dogs, and cats.

As used herein, a “manifestation” of a disease refers to a symptom,sign, anatomical state (e.g., lack of islet cells), physiological state(e.g., glucose level), or report (e.g., triglyceride level)characteristic of a subject with the disease.

As used herein, a “therapeutically effective amount” of a drug or agentis an amount of a drug or agent that, when administered to a subjectwith a disease or condition, will have the intended therapeutic effect,e.g., alleviation, amelioration, palliation or elimination of one ormore manifestations of the disease or condition in the subject. The fulltherapeutic effect does not necessarily occur by administration of onedose and may occur only after administration of a series of doses. Thus,a therapeutically effective amount may be administered in one or moreadministrations.

As used herein, a “prophylactically effective amount” of a drug is anamount of a drug that, when administered to a subject, will have theintended prophylactic effect, e.g., preventing or delaying the onset (orreoccurrence) of disease or symptoms, or reducing the likelihood of theonset (or reoccurrence) of disease or symptoms. The full prophylacticeffect does not necessarily occur by administration of one dose and mayoccur only after administration of a series of doses. Thus, aprophylactically effective amount may be administered in one or moreadministrations.

As used herein, “TID”, “QD” and “QHS” have their ordinary meanings of“three times a day”, “once daily,” and “once before bedtime”,respectively.

Administration of an agent “in combination with” includes paralleladministration (administration of both the agents to the patient over aperiod-of time, such as administration of a monoclonal antibody and apeptide hormone such as an incretin hormone or analog on alternate daysfor one month), co-administration (in which the agents are administeredat approximately the same time, e.g., within about a few minutes to afew hours of one another), and co-formulation (in which the agents arecombined or compounded into a single dosage form suitable for oral,subcutaneous or parenteral administration).

DPP-4 Inhibitors are dipeptidyl peptidase-4 inhibitors.

Hamster INGAP is a non-human islet neogenesis associated peptide.

GIP is Gastric Inhibitory Peptide, also known as Glucose-DependentInsulinotropic Polypeptide.

GLP-1 is Glucagon-like Peptide 1.

HIP is one of the Human proIslet Peptides in purified, synthetic, orrecombinant form, or incorporated into a pharmaceutical composition.

Derivatives and analogs may be full length or other than full length.Derivatives or analogs of the nucleic acids or proteins of the inventioninclude, but are not limited to, molecules comprising regions that aresubstantially homologous to the nucleic acids or proteins of theinvention, in various embodiments, by at least about 70%, 80%, or 95%identity (with a preferred identity of 80-95%) over a nucleic acid oramino acid sequence of identical size or when compared to an alignedsequence in which the alignment is done by a computer homology programknown in the art, or whose encoding nucleic acid is capable ofhybridizing to the complement of a sequence encoding the proteins understringent, moderately stringent, or low stringent conditions. See e.g.Ausubel, et al., CURRENT PROTOCOLS IN MOLECULAR BIOLOGY, John Wiley &Sons, New York, N.Y., 1993, and below.

Islet Structures

There has been confusing nomenclature in the literature regarding theregenerative processes of the pancreas. Often the term islet “cell” hasbeen used synonymously with beta cells and this distinction is importantas new therapies for the treatment of diabetes are considered. Thepancreatic islets are not cells, but are structures, each of which iscomposed an estimated 1000 cells of four distinct cell types: 1) Betacells which make insulin and amylin and comprise 65-80% of the isletcells 2) Alpha cells which release glucagons and make up 15-20% of thecells 3) Delta cells making somatostatin and 4) Pancreatic polypeptide(PP) cells sometimes referred to as gamma cells. Delta and PP cellscomprise less than 10% of the islet structure. Islet structures compriseonly 1-2% of the pancreatic mass, yet utilize 20% of the blood supply tothe pancreas and are considered one of the most vascularized cell typesin the body.

There is a highly organized arrangement of the four types of cellswithin the islet structure. The delivery of blood flow within each isletis in a centrifugal manner with the beta cells located most centrally,and therefore receiving the core blood supply, while the alpha, deltaand pancreatic polypeptide cells are positioned outside the beta cellsin a lower order of perfusion.

In addition to glucose levels, which affect the beta cells, beta cellsare coupled electrically to other beta cells, but not to other islet orpancreas cells. This elaborate system of communication within the isletmay explain a compensatory rise in alpha cells within an islet whenthere is a significant decline in the beta cell mass (Kun et al., J ClinEndocrinol Metab 88: 2300-2308, 2003, Li et al., Journal ofEndocrinology (2000) 165, 93-99).

Human proIslet Peptides (HIPs)

The Human proIslet Peptides (HIPs) and analogs thereof of the inventionare active fragments of human REG3A or pancreatitis-associated proteinprecursor on chromosome 2p12. The REG3A protein from which the HIPs ofthe invention are derived is shown in Table 1. The domain which providesthe HIPs of the invention is shown in boldface.

TABLE 1 REG3A/Pancreatitis-associated proteinprecursor amino acid sequence amino acid sequence.MLPPMALPSVSWMLLSCLMLLSQVQGEEPQRELPSARIRCPKGSKAYGSHCYALFLSPKSWTDADLACQKRPSGNLVSVLSGAEGSFVSSLVKSIGNSYSYVWIGLHDPTQGTEPNGEGWEWSSSDVMNYFAWERNPSTISSPGHCASLSRSTAFLRWKDYNCNVRLPYVCKFTD (SEQ ID NO: 1)

HIP and analogs and derivatives thereof of the invention include thepolypeptides shown below in Table 2 in purified, synthetic, orrecombinant form, or contained in a pharmaceutical composition.

TABLE 2 Sequence of Human proIslet Peptide (HIP) analogs IGLHDPTQGTEPNGEHIP SEQ ID NO: 2 IGLHDPTQGTEPNG Glutamate- SEQ ID less HIP NO: 3VWIGLHDPTQGTEPNGE Valine-Tryp SEQ ID HIP Analog NO: 4 IGLHDP HexapeptideSEQ ID HIP NO: 5 WIGLHDP Septapeptide SEQ ID HIP NO: 6 WIGLHDPTQGTEPNGTryp-Glutamate- SEQ ID less HIP NO: 7 WIGLHDPTQGTEPNGE Tryp-HIP SEQ IDNO: 19 IGLHDPT Second Septa- SEQ ID peptide HIP NO: 18

These peptides are the human homologues of the hamster INGAP peptidedisclosed in U.S. Pat. No. 5,834,590, incorporated, herein, by referencein its entirety. This patent discloses a hamster islet neogenesisassociated protein (INGAP) and associated peptides at least 15 aminoacids in length. A BLAST2P alignment of human REG3A and hamster INGAPperformed on the NCBI website is shown below in Table 3.

TABLE 3 BLAST2P alignment of REG3A (SEQ ID NO: 1)and golden hamster INGAP (SEQ ID NO: 8). REG3: 1MLPPMALPSVSWMLLSCLMLLSQVQGEEPQRELPSARIRCPKGSKAYGSHCYALFLSPKS 60 M+PM L  +SWMLLSCLM LS V+GEE Q++LPS+RI CP+GS AYGS+CY+L L P++ INGAP: 1MMLPMTLCRMSWMLLSCLMFLSWVEGEESQKKLPSSRITCPQGSVAYGSYCYSLILIPQT 60 REG3: 61WTDADLACQKRPSGNLVSVLSGAEGSFVSSLVKSIGNSYSYVWIGLHDPTQGTEPNGEGW 120W++A+L+CQ   SG+L  +LS  E +FVSSLVK+   +Y Y+WIGLHDP+ GT PNG GW INGAP: 61WSNAELSCQMHFSGHLAFLLSTGEITFVSSLVKNSLTAYQYIWIGLHDPSHGTLPNGSGW 120 REG3:121 EWSSSDVMNYFAWERNPSTISSPGHCASLSRSTAFLRWKDYNCNVRLPYVCKF 173 +WSSS+V+++ WERNPS  +  G+CA LS+ + F +W+D+NC   LPY+CKF INGAP: 121KWSSSNVLTFYNWERNPSIAADRGYCAVLSQKSGFQKWRDFNCENELPYICKF 173

In boldface in Table 3 above, is the domain in REG3A from which HIP (SEQID NO:2) is derived and the corresponding hamster sequence in INGAP. InU.S. Publication No. 20040132644, incorporated herein by reference inits entirety, an INGAP peptide shown in bold above in Table 3 isdisclosed. This hamster INGAP peptide is being studied for its efficacyin islet neogenesis.

The present invention has also enabled the identification ofcorresponding HIP-like peptides from animals in addition to thepreviously known hamster INGAP, and thus, in one important aspect,provides these peptides and their analogs in substantially pure andrecombinant form, as well as pharmaceutical preparations containingthem, and therapeutic methods for using them to increase insulinproduction. While each of these HIP-like peptides from animals otherthan hamster are particularly suited for practicing the method of theinvention in the animal or origin, those of skill in the art willrecognize from this disclosure that these peptides can also be used inanimals other than the animal of origin and in humans in accordance withthe teachings of the invention.

Table 4, below, shows illustrative non-human HIP-like peptides providedby the present invention; the hamster INGAP sequence is shown forcomparison purposes.

TABLE 4 Alignment of HIP homologous Sequences from other MammalianSpecies.

The mutations shaded above in Table 4 are summarized below.

M = Methionine/ both non-polar hydrophobic I = Isoleucine SNP AT

 vs AT

W = Tryptophan/ subst: Non-polar hydrophobic/ G = Glycinepolar uncharged

GG vs 

GG SNP S = Serine/ both polar uncharged T = ThreonineFour possible SNP's

CX vs 

CX with same result L = Leucine/ subst: non-polar hydrophobic/ Q =Glutamine polar uncharged C

G vs C

G One Possible SNP E = Glutamic acid/ subst: polar uncharged Q Glutaminewith Acidic

AA/GA

 vs CA

/CA

Two possible SNPs N = Asparagine/ subst: polar uncharged/acidic D =Aspartic acid Two possible SNPs =

AT/

AC vs 

AT/

AC same result G = glycine/ subst: polar uncharged/ A = Alaninenon-polar hydrophobic G

X vs G

X Four possible SNPs with  same result

The novel HIP and HIP-like peptide sequences provided by the presentinvention are highly homologous, reflecting the importance of thefunction of such peptides—to induce pancreatic islet neogenesis. Thisconservation of sequence, relative to that of the hamster INGAP,provides further demonstration that HIP and its analogs and derivatives,including the non-hamster HIP-like peptides shown in Table 4 above, areefficacious in stimulating islet neogenesis as provided herein.

Microarray analysis of gene expression in NOD mice has shown theupregulation of the Reg genes specifically in islet neogenesis(Vukkadapu et al, Physiol Genomics. 2005 Apr. 14; 21(2):201-11). Inaddition, Reg genes have been known to upregulate in late fetaldevelopment to populate the pancreas of a developing human to maintainits own glucose metabolism post partum. Hao et al, 2006, Nature Medicine12(3):310-6 showed that co-transplantation of fetal tissue withnon-endocrine pancreatic epithelials cells (NEPECs) resulted instimulation of new islet structures from the NEPEC population. Theupregulation of Reg and therefore the abundance of HIP in theco-transplanted fetal material was likely the stimulus for this effect.

Hamster INGAP has been subject to clinical trials. While hamster INGAPhas been shown to be well tolerated in Phase I and II trials, a Phase IItrial had high drop out of diabetic patients due to discomfort andbruising at the hamster INGAP injection site. Little effectiveness wasfound for hamster INGAP in the Phase II trial as well. The HIP inventionshould not have the same drop out problems because they are derived fromhuman, as opposed to hamster sequences. Further, HIP and derivatives andanalogs thereof may be administered at an increased number of doses aday. The number of daily doses may be 2, 3, 4, 5, 6, 7, 8, 9 or 10. Thedoses may be given before meals to increase effectiveness in somepatients. It is hypothesized that HIP stimulates differentiation ofprogenitor cells within the pancreas into new islet structures and issecreted in response to mild hyperglycemia. Administration of HIPimmediately prior to meals and being present during hyperglycemiafollowing ingestion of the meal mimics the wild type secretion schedule,which may cause more effective treatment in patients.

Despite the adverse effects shown in the Phases II hamster INGAP trials,INGAP did show some signs of effectiveness in the trials. Patientstreated with 600 mgday of hamster INGAP showed an increase in C-peptidesecretion.

Also, in the 300 mgday treatment group of the Phase II study, 22% of thepatients had a >50% increase in GAD65 antibody titers. GAD65 antibodybinds to lymphocytes which attack beta cells within the islets. Thus arise in GAD65 antibody titers reflects new beta cell productionassociated with islet neogenesis stimulated by hamster INGAP.

Also, hemoglobin A1C fell in type 2 diabetes patients. This iscorrelated a decrease in glycemic exposure, and thus a lower averageblood glucose. This also suggests that hamster INGAP is having somepositive effect on islet function in patients, despite its adverseeffects, shown in the Phase II study for hamster INGAP.

HIP analogs of the invention include any peptide comprising at least a 6amino acid sequence from the boldface sequence shown above, i.e. SEQ IDNO:2. For example, peptide sequences of 15 amino acids or less (i.e.having 6, 7, 8, 9, 10, 11, 12, 13, or 14 amino acids) comprising any ofthe 6 amino acid sequences shown in Table 5 are contemplated as peptidesof the invention.

TABLE 5 Embodiments of sequences  comprised within HIP analogs. SEQ IDPeptide NO: IGLHDP 5 GLHDPT 9 LHDPTQ 10 HDPTQG 11 DPTQGT 12 PTQGTE 13TQGTEP 14 QGTEPN 15 GTEPNG 16 TEPNGE 17

In one embodiment, the HIP of the invention provided in purified,synthetic, or recombinant form induces pancreatic islet neogenesis andis entirely comprised of human sequence. These peptides are advantageousrelative to the non-human HIP homologues, such as the hamster INGAP,because they do not contain any non-human peptide sequence. Thus, thereis little chance for immune reaction when these peptides areadministered to humans, as opposed to the hamster INGAP peptides.

Further, the HIP peptides of the invention may be stably stored for longperiods of time. HIP peptides of the invention are stable for monthswhen stored at 20° C. in isotonic saline.

In a specific embodiment, the derivative or analog is functionallyactive, i.e., capable of exhibiting one or more functional activitiesassociated with HIP. Derivatives or analogs of HIP can be tested for thedesired activity by procedures known in the art, including but notlimited to, using appropriate cell lines, animal models, and clinicaltrials. For example, assays described in Jamal, A. M., et al. Cell DeathDiffer. 2005 July; 12(7):702-12, incorporated herein by reference in itsentirety, may be used.

In particular, HIP derivatives can be made via altering HIP sequences bysubstitutions, insertions, or deletions that provide for functionallyequivalent or improved molecules. Due to the degeneracy of nucleotidecoding sequences, other DNA sequences which encode the same or asubstantially similar amino acid sequence as HIP or analogs orderivatives thereof may be used in the practice of the presentinvention. These include, but are not limited to, nucleic acid sequencescomprising all or portions of HIP that are altered by the substitutionof different codons that encode a functionally equivalent amino acidresidue within the sequence, thus producing a silent change. Likewise,the HIP derivatives of the invention include, but are not limited to,those containing, as a primary amino acid sequence, all or part of theamino acid sequence of HIP including altered sequences in whichfunctionally equivalent amino acid residues are substituted for residueswithin the sequence resulting in a silent change. For example, one ormore amino acid residues within the sequence can be substituted byanother amino acid of a similar polarity that acts as a functionalequivalent, resulting in a silent alteration. Substitutes for an aminoacid within the sequence may be selected from other members of the classto which the amino acid belongs. For example, the nonpolar (hydrophobic)amino acids include alanine, leucine, isoleucine, valine, proline,phenylalanine, tryptophan and methionine. The polar neutral amino acidsinclude glycine, serine, threonine, cysteine, tyrosine, asparagine, andglutamine. The positively charged (basic) amino acids include arginine,lysine and histidine. The negatively charged (acidic) amino acidsinclude aspartic acid and glutamic acid. HIP derivatives of theinvention also include, but are not limited to, those containing, as aprimary amino acid sequence, all or part of the amino acid sequence ofHIP including altered sequences in which amino acid residues aresubstituted for residues with similar chemical properties. In a specificembodiment, 1, 2, 3, 4, or 5 amino acids are substituted.

Derivatives or analogs of HIP include, but are not limited to, thoseproteins which are substantially homologous to HIP or fragments thereof,or whose encoding nucleic acid is capable of hybridizing to the HIPnucleic acid sequence.

In a specific embodiment, chimeric or fusion proteins may be used in themethod of the invention. As used herein, a “chimeric protein” or “fusionprotein” comprises HIP or an analog or derivative thereofoperatively-linked to a non-HIP or an analog or derivative thereof.Within such a fusion protein, the HIP or analog or derivative thereofcan correspond to all or a portion of HIP. In one embodiment, a HIPfusion protein comprises at least one biologically-active portion ofHIP. Within the fusion protein, the HIP or analog or derivative thereofand the non-HIP polypeptide are “operatively-linked”, that is they arefused in-frame with one another. The non-HIP polypeptide can be fused tothe N-terminus or C-terminus of the HIP or analog or derivative thereof.For example, the fusion protein may be a HIP protein containing aheterologous signal sequence at its N-terminus. In certain host cells(e.g., mammalian host cells), expression andor secretion of HIP or ananalog or derivative thereof can be increased through use of aheterologous signal sequence. In yet another example, the fusion proteinis a HIP-immunoglobulin fusion protein in which the HIP sequences arefused to sequences derived from a member of the immunoglobulin proteinfamily. The HIP-immunoglobulin fusion proteins can be incorporated intopharmaceutical compositions and administered to a subject to inhibit animmunological response according to the present invention.

HIP, an analog or derivative thereof, or a HIP-chimeric or fusionprotein for use in the methods of the invention may be chemicallymodified for the purpose of improving bioavailability, andor increasingefficacy, solubility and stability. For example, the protein may becovalently or non-covalently linked to albumin, transferrin orpolyethylene glycol (PEG).

HIP, an or analog or derivative thereof, or a HIP-chimeric or fusionprotein for use in the method of the invention can be produced bystandard recombinant DNA techniques in accordance with the teachings ofthe invention. For example, DNA fragments coding for the differentpolypeptide sequences may be ligated together in-frame in accordancewith conventional techniques, e.g., by employing blunt-ended orstagger-ended termini for ligation, restriction enzyme digestion toprovide for appropriate termini, filling-in of cohesive ends asappropriate, alkaline phosphatase treatment to avoid undesirablejoining, and enzymatic ligation. Furthermore, the fusion gene can besynthesized by conventional techniques including automated DNAsynthesizers. Alternatively, PCR amplification of gene fragments can becarried out using anchor primers that give rise to complementaryoverhangs between two consecutive gene fragments that can subsequentlybe annealed and reamplified to generate a chimeric gene sequence [see,e.g., Ausubel, et al. (eds.) CURRENT PROTOCOLS IN MOLECULAR BIOLOGY,John Wiley & Sons, (1992)]. Moreover, many expression vectors arecommercially available that already encode a fusion moiety (e.g., a GSTpolypeptide). A HIP-encoding nucleic acid can be cloned into such anexpression vector such that the fusion moiety is linked in-frame to HIP.The fusion protein can be a HIP protein fused to a His tag or epitopetag (e.g. V5) to aid in the purification and detection of therecombinant HIP, or to mask the immune response in a subject. Therelatively short amino acid sequences of HIP and its analogs andderivatives make synthetic production of these valuable peptides readilypracticable as well, and a variety of automated instruments for peptidesynthesis are commercially available, and synthetic methods for peptidesynthesis not requiring automation have long been known and can be usedin accordance with the teachings herein to prepare a HIP or analog orderivative of the invention.

In some embodiments, HIP, an or analog or derivative thereof, or aHIP-chimeric or fusion protein can be modified so that it has anextended half-life in vivo using any methods known in the art. Forexample, Fc fragment of human IgG or inert polymer molecules such ashigh molecular weight polyethyleneglycol (PEG) can be attached to HIP oran analog or derivative thereof with or without a multifunctional linkereither through site-specific conjugation of the PEG to the N- orC-terminus of the protein or via epsilon-amino groups present on lysineresidues. Linear or branched polymer derivatization that results inminimal loss of biological activity will be used. The degree ofconjugation can be closely monitored by SDS-PAGE and mass spectrometryto ensure proper conjugation of PEG molecules to HIP or an analog orderivative thereof. Unreacted PEG can be separated from HIP-PEGconjugates by size-exclusion or by ion-exchange chromatography.PEG-derivatized conjugates can be tested for in vivo efficacy usingmethods known to those of skill in the art.

Methods of the Invention and Agents Useful Therein OVERVIEW OF THEMETHODS OF THE INVENTION

The present invention provides HIP or HIP derivative or analog basedtherapies and methods for increasing insulin and other pancreatichormone production or activity in a subject. In one embodiment, themethod is practiced to treat type 1 or type 2 diabetes mellitus andrelated conditions in which there is a lack of or diminished insulinproduction in a patient resulting in aberrant glucose metabolism. Themethod comprises administering to that patient an agent that stimulatespancreatic islet regeneration andor differentiation from pancreaticprogenitor cells into islet structures. This agent is HIP or an analogor derivative thereof. Optionally, HIP or HIP analog or derivative isadministered with the simultaneous or contemporaneous administration ofan agent that inhibits the activity of and or blocks or destroys theautoimmune cells that target pancreatic islet beta cells and optionallyanother agent which may also stimulates pancreatic beta cellregeneration andor result in elevation of GLP-1 or GLP-1 receptorstimulation or is a GLP-1 analog, or is a Dipeptidyl Peptidase-4Inhibitor, which inhibits the degradation of GLP-1.

The therapeutic methods provided by the present invention addressseveral different underlying mechanisms that result in either theabsence of, or diminished or inadequate amounts of, insulin and otherhormones, or which are otherwise produced in aberrant quantities. TheHIP based, combination therapies provided by the present invention canrestore more normal glucose metabolism, including achieving andmaintaining appropriate levels of insulin, amylin, postprandial glucose,triglycerides, and glucagon levels and ameliorate the significant weightgain and increased risk for serious hypoglycemia that is associated withtight glycemic control using insulin or oral diabetic medications.

The present invention also provides single agent therapies for treatinginsulin deficiency, including diabetes and related conditions. Thesesingle agent therapies include methods for the administration of HIP orHIP analogs or derivatives thereof that stimulate pancreatic islet cellregeneration andor transformation of new insulin producing islet cellsfrom pancreatic progenitor cells located within the adult pancreas. Theislet cell neogenesis resulting from such administration with HIP can beused to treat diabetes and other diseases and conditions relating toaberrant glucose regulation. In various embodiments, these methodsinvolved the administration of such agents, including but not limited toHIP, tryptophan-HIP, glutamate-less HIP, valine-trypytophan HIP analog,hexapeptide HIP, septapeptide HIP, second septapeptide HIP ortryptophan-glutamate-less HIP, alone or in combination with an immuneblocking agent andor co administered with a GLP-1 receptor agonist,GLP-1, GLP-1 analog, or Dipeptidyl peptidase-inhibitor in the case fortype 1 diabetes or HIP in combination with GLP-1 receptor agonist,GLP-1, GLP-1 analog, or dipeptidyl peptidase-inhibitor without the needfor an immune blocker in the case of type 2 diabetes. Disease conditionsamenable to treatment with this methodology, include, but are notlimited to type 1 and 2 diabetes, where these treatments can be used toimprove glycemic control, as measured by hemoglobin A1C, and to reducebolus insulin before meals by 10-20%, with reduced fluctuations anddecreased postprandial glucose, glucagon, and triglycerides. Thesemethods can also be used to prevent progression of impaired glucosetolerance to diabetes and to prevent progression of impaired fastingglucose to progression to impaired glucose tolerance and diabetes and toreverse newly diagnosed type 2 diabetes. These methods can also be usedto treat type 2 diabetes.

Exogenous injectable insulin is a therapy for patients with type 1diabetes and other conditions in which insulin is either absent orpresent in diminished or inadequate amounts relative to the glucosecontent in the bloodstream. Insulin therapy does not treat theunderlying mechanisms disease resulting in type 1 diabetes and othersuch conditions in which there is diminished endogenous insulinproduction. The therapies, methods, modalities, and treatments describedherein are the first to address the many facets of the cause andcomplications of diabetes. The unique therapies provided by theinvention encompass diverse aspects diabetology, metabolism, andimmunology. These therapies include those that restore normal levels ofthe many different hormones, in addition to insulin, that are diminishedor absent in type 1 diabetes. The methods of the invention provide forthe regeneration of new insulin producing cells and optionallyimmuno-modulation that together serve to ameliorate, diminish, orabolish the need for insulin among patients with type 1 diabetes andother conditions associated with inadequate insulin production andsecretion.

In type 1 diabetes, there are several underlying mechanisms that resultin significant reduction in the production of insulin. These includeautoimmune destruction of the beta cells and reduction in regenerationcapacity not only within the beta cells, but an inability of progenitorcells to differentiate into new islets may be due to the altered glucosemilieu. The present invention also provides combination treatmentmethods that are especially efficacious, because when the autoimmuneresponse is blocked by the co-administration with HIP or a HIP analog orderivative of an immunosuppressant, the autoimmune cells that attack thepancreatic islet cells are blocked, and peptides or other compounds thatstimulate regeneration of the pancreatic islet cells are administered,the patient becomes less dependent on insulin administration.

The methods of the invention can even render some patients completelyfree of their dependence on administered insulin for both type 1 and 2diabetes. Other studies (see the references Levetan et al., 2002,Diabetes 51(supple 2):429, Levetan et al. Diabetes 2002. 51(suppl.2):474, Levetan Diabetes 2001; 50(supple 2):2105 PO. and Levetan et al.,2003, Diabetes Care 26:1-8, both incorporated herein by reference) showthat, when diminished hormones other than insulin are replaced, insulinrequirements in type 1 patients are significantly diminished withimproved glucose control. By stimulating differentiation of new insulinproducing islet structures and optionally blocking the immune cells thatcan destroy their function, the methods of the present invention haveeven greater promise, because they result in sustained, endogenousproduction of insulin itself, and other co-secreted hormones such asamylin.

There is a demonstrated need for the therapeutic benefits provided bythe present invention. There are new insulin formulations and evidenceto support that intensive insulin therapy prevents deaths and reducesthe rate of blindness, amputations, and kidney failure necessitatingdialysis. However, intensive insulin therapy utilizing modern modalitiesof multiple insulin injections and continuous insulin delivery via pumptherapy is associated with a two-to-three fold increased risk of serioushypoglycemia requiring assistance from another person. In a clinicalstudy setting, despite normalization of glucose in type 1 diabetespatients by means of intravenous insulin and glucose, the standarddeviation in glucose levels, both high and low, is significantly widerthan non-diabetic study subjects with the same average glucose over a24-hour period. The present invention offers an alternate means toachieve the therapeutic benefit of intensive insulin therapy withoutreduced iatrogenic risk, because the endogenous production of insulinstimulated by the present methods should provide more normal rates ofinsulin production than can not be effectively mimicked by intensiveinsulin therapy.

Thus, despite insulin's availability and new technologies, including newformulations of human insulin, self blood glucose monitoring systems,continuous glucose sensors and pump therapy, normal glucose control isnot approximated by current therapies. Moreover, the underlyingmechanisms causing type 1 diabetes are not impacted by the currenttherapies available for patients with type 1 diabetes and conditions inwhich there is no or diminished or inadequate or otherwise aberrantinsulin or amylin production and dysregulation of glucagon.

The present invention provides new methods and pharmaceuticalcompositions for stimulating islet neogenesis, increasing insulin orother pancreatic hormone production in a patient in need thereof, andtreating type 1 diabetes mellitus, type 2 diabetes mellitus and otherconditions in which the lack of or diminished insulin production is acausative factor for the disease symptoms. The methods and compositionsof the invention can reverse the underlying pathologic mechanisms ofthese disease conditions. Thus, the methods of the invention diminish,and in some cases eliminate, the need for insulin administration topatients formerly in need thereof.

In one embodiment of this method, an agent that stimulates isletregeneration andor differentiation from pancreatic progenitor cells intoinsulin producing islet structures is co-administered with HIP or ananalog or derivative thereof including glutamate-less HIP,tryptophan-HIP, valine-trypytophan HIP analog, hexapeptide HIP,septapeptide HIP, second septapeptide HIP, or tryptophan-glutamate-lessHIP. This agent that stimulates islet regeneration andor differentiationfrom pancreatic progenitor cells into insulin producing islet structuresmay be HIP or an analog or derivative thereof as well as long as it isdifferent from the first administered HIP or analog or derivativethereof. Agents that be administered with HIP or during the stepwisemethods of HIP usage for the treatment of type 1 and type 2 diabetesinclude amylin andor an analog, such as Pramlintide, GIP, GLP-1 andorhomologous compounds and analogs, GLP-1 receptor analogs which includeExendin-4, Liraglutide (NN2211), hamster INGAP, or HIP analogs thereof,any biologically active HIP peptide andor the Dipeptidyl Peptidase-4inhibitors, which delay the degradation of GLP-1. The second agent mayaffect beta cell regeneration, gastric emptying, satiety, insulinrequirements through their impacting the GLP-1 and amylin receptor sitesin the pancreas, nucleus accumbens, area postrema, and gut and may beused in such an embodiment of the method, with HIP or an analog orderivative thereof from the one first administered.

One method of treating type 1 diabetes and other pathologies resultingfrom diminished pancreatic function, includes a five step process. Thesesteps include: 1) Intensive Glycemic Management, 2) Achievement andmaintenance of 25-hyrdroxyvitamin D levels to >40 ngdl via oralcholecalciferol (Vitamin D3) 3) Immune Therapy, 4) HIP administrationand Insulin tapering followed by discontinuation of both HIP and Insulinand 5) Repeated usage of immune modulation on a quarterly or annualbasis dependent on immune therapy chosen.

Another method includes a two step process for the treatment of type 2diabetes, obesity, overweight, insulin resistance, hyperlipidemia,hypertriglyceridemia, and eating disorders. This process includes thesteps of: 1) Achievement and maintenance of 25-hyrdroxyvitamin D levelsto >40 ngdl via oral cholecalciferol (Vitamin D3) and 2) Administrationof HIP in combination with a GLP-1 or GLP-1 receptor agonist or GLP-1analog or Dipeptidyl Peptidase-4 Inhibitor.

The first two steps of the five step process of treating type 1 diabetesand other pathologies resulting from diminished pancreatic function aredescribed in more detail below. For the first step, a three-month timeperiod prior to the administration of HIP or HIP analog or derivativeadministration and prior to or with the simultaneous or contemporaneousadministration of an agent that inhibits the activity of and or blocksor destroys the autoimmune cells that target islet beta cells, therewill be a period of tightintense glucose optimization. This period oftightintense glucose optimization may include multiple daily dosages ofinsulin administered subcutaneously or via continuous subcutaneousadministration through an insulin pump and may include theadministration of synthethic amylinPramlintide (Symlin™), which is alsoabsent in type 1 diabetes and aberrantly secreted in type 2 diabetes.Synthetic amylinPramlintide (Symlin™), has been shown to reduce glycemicexcursions in type 1 patients, while reducing insulin requirementsbefore meals (Levetan. Diabetes Care. 2003; 26(1):1-8).

Additionally, throughout the period of tight control, immune therapy,and HIP administration, the administration of vitamin D3,cholecalciferol may be administered at a dosage of 1000-2000 IUday.Recent studies have demonstrated that up to 54.7% of populations in theUS, regardless of latitude, have low 25-hydroxyvitamin D levels (Holick,J Clin Endorinol Metab 2005; 90-3215-3224). Vitamin D deficiency hasbeen demonstrated, not only to be associated with the increased risk oftype 1 diabetes and seen at the onset of type 1 diagnosis, but also iscommonly seen among both patients with type 1 and 2 diabetes andmaintaining levels above 40 ngml are recommended to maintain normalimmune function in those with and without diabetes (Riachy Apoptosis.2006 February; 11(2):151-9. Holick. Mayo Clin Proc. 2006 March;81(3):353-73, Grant. Prog Biophys Mol Biol. 2006 Feb. 28; [Epub ahead ofprint]. DiCesar. Diabetes Care. 2006 January; 29(1):174, Reis. DiabetesMetab. 2005; 31(4 Pt 1):318-25, Pozzilli. Horm Metab Res. 2005;37(11):680-3). No adverse effects have been seen with dosages up to10,000 IUday (Heaney. Am J Clin Nutr, 204-210, Vieth. Am J Clin Nutr.2001; 73:288-294). Vitamin D in dosages of 1000-2000 IUday are continuedto maintain 25-hydroxyvitamin D levels >40 ngdl for both type 1 and 2diabetes patients.

Step 2. Prior to the administration of the HIP or HIP analog orderivative, one of the immune modulators will be administered in itsprescribed methods. Such immune modulators include immunomodulatorypeptides that arrest pancreatic islet cell destruction. For example, onesuch immune modulator is a monoclonal antibody that can delay theprogression of islet loss or slow or stop the onset of type 1 diabetes.Anti-CD3 antibodies constitute a general class of agents useful in themethods of the invention. For example, suitable anti-CD3 antibodies forpurposes of the present invention include the TRX4 (Ala-Ala andChAglyCD3) antibody under development by TolerRx and the humanizedanti-CD3 antibody described in the reference Herold et al., 30 May 2002,NEJM346(22):1692-1698, incorporated herein by reference. In oneembodiment, the Bluestone humanized anti-CD3 antibody is deliveredintravenously, 14 days per year in the dosage of 1-1.42 μgkg on day 1,5.67 μgkg on day 2, 11.3 μgkg on day 3, 22.6 μgkg on day 4 and 45.4 μgkgon days 5-14. These therapies would also be repeated annually followingthe 3-6 month usage of HIP, while insulin is being tapered as new isletcell formation occurs. During the HIP treatment phase, Vitamin D or theusage of pramlintideSymlin™ may be continued. Following thediscontinuation of HIP and insulin therapy, immune modulation will berepeated annually for the anti-CD3 antibodies, though recent study hasfound their efficacy to continue for as long as 24 months (Herold.Diabetes. 2005; 54(6):1763-9).

In another embodiment, the immuno-modulatory compound is a lysofyllineor a heat shock protein that can arrest or slow islet cell destruction.Such proteins include DIAPEP277™, a heat-shock protein under developmentby Develogen AG (see the reference Raz et al., 2002, Lancet358(9295):1749-53, incorporated herein by reference). In one embodiment,DIAPEP277™ is delivered subcutaneously by giving 1 mg in 40 mg mannitolin vegetable oil subcutaneously at baseline and at one month and then at3 month intervals. DIAPEP277™ is continued throughout HIP therapy andfollowing HIP therapy at quarterly intervals to protect newly generatedislets from HIP therapy. In one embodiment of the combination therapy ofthe invention, HIP is co-administered with DIAPEP277™ as follows. TheDIAPEP277™ is first administered subcutaneously at a dose of about 1 mg,about 30 days prior to the initiation of the HIP therapy. A secondadministration of the DIAPEP277™ is then made at the time (30 days afterthe first administration) of initiating the HIP therapy. The HIP therapymay be repeated as necessary, and the DIAPEP277™ is administered at afrequency of about every 3 months.

In another embodiment, hamster INGAP may be delivered by 24 hourcontinuous subcutaneous infusion at a dose of about 8 to 18 mg per kg ofpatient body weight per 24 hours. The HIP therapy may be repeated asnecessary, and the DIAPEP277™ is administered at a frequency of aboutevery 3 months.

The new HIP therapeutic methods provided by the present inventionaddress several different underlying mechanisms that result in eitherthe absence of, or diminished or inadequate amounts of insulin and otherhormones or which are otherwise produced in aberrant quantities. The HIPbased, HIP analog or derivative based, or combination therapies providedby the present invention can restore more normal glucose metabolism,including achieving and maintaining appropriate levels of insulin,amylin, postprandial glucose, triglycerides, and glucagon and amelioratethe significant weight gain and increased risk for serious hypoglycemiathat is associated with tight glycemic control.

Those of skill in the art will appreciate in view of the disclosureherein that more than one agent that stimulates islet neogenesis andorprogenitor cell differentiation andor which slows the degradation ofsuch agents can be used in combination in the methods of the invention.

Optionally, in the practice of the methods of the invention, the HIP oranalog or derivative thereof, with or without the co-administration ofanother selected agent, such as Symlin™pramlintide GLP-1, a GLP-1receptor agonist, GLP-1 agonist, or dipeptidyl-4 peptidase inhibitor,which inhibits the degradation of GLP-1, which may reduce weight,improve satiety, slow gut absorption of glucose may be used incombination with a specific agent that inhibits, blocks the activity of,or destroys autoimmune cells that target the pancreatic beta cells. Suchagents include, for example, peptides, proteins, and syntheticcompounds.

In one embodiment, the agent is a monoclonal antibody, a heat-shockprotein, or another compound that specifically delays, prevents, orhalts autoimmune destruction of the islet function. Those of skill inthe art will appreciate in view of the disclosure herein that more thanone agent that blocks autoimmune destruction of pancreatic isletfunction can be used in combination in the methods of the invention.Agents that inhibit, block the activity of, or destroy autoimmune cellsthat target the pancreatic islet function include: Anti CD-3 antibodies(hOKT3 Ala-Ala and ChAglyCD3), Sirolimus (Rapamycin), Tacrolimus(FK506), a heat-shock protein 60 (DiaPep277) a anti-Glutamic AcidDecarboxylase 65 (GAD65) vaccine, Mycophenolate Mofetil alone or incombination with Daclizumab, the anti-CD20 agent Rituximab, Campath-1H(Anti-CD52 Antibody), lysofylline, and Vitamin D, IBC-VSO vaccine whichis a synthetic, metabolically inactive form of insulin designed toprevent pancreatic beta-cell destruction, interferon-alpha. vaccinationusing CD4⁺CD25⁺ antigen-specific regulatory T cells or a similar agent,designed to prevent pancreatic beta-cell destruction. In this latterembodiment, interferon-α vaccination using CD4⁺CD25⁺ antigen-specificregulatory T cells or a similar agent is used in the combination therapyfor utilizing regulatory T cells either directly or through the use ofanti-CD3 immunotherapy. This embodiment, which includes an immune agentwould specifically be used in type 1 diabetes patients to protect newlygenerated islet cells from immune attack.

Thus, the combination therapies and related methods of the inventioninvolve the administration of HIP or analogs or derivatives thereof orco-administration of HIP or analogs or derivatives thereof with one ormore agents that stimulate islet differentiation from cells in the adultpancreas with one or more agents that block autoimmune destruction ofpancreatic beta cells. As used herein, an agent is “co-administered” or“used in combination” with another agent (also referred to herein as,“compound or “hormone”) when the two or three agents are administered aspart of the same course of therapy. In one embodiment, a first agent isfirst administered prior to administration of the second agent, andtreatment with both is continued throughout the course of therapy. Inanother embodiment, the second agent is administered after theinitiation or completion of the therapy involving the first agent. Inother embodiments, the first agent is administered contemporaneouslywith the initiation of the therapy with the second agent. In anotherembodiment, a third agent is administered contemporaneously or before orafter the administration of the first or second agent or both. In oneembodiment, a therapy involving one or more agents to block or killautoimmune cells that target pancreatic beta cells, which make insulinand amylin, is first administered prior to administration of the therapythat stimulates islet differentiation from progenitor cells in the adultpancreas. In another embodiment, treatment with the specific autoimmuneblocker is continued after the cessation of treatment with agents thatstimulate islet differentiation. Prior to or contemporaneouslyadministration of immune modulating agents, there will be a three monthperiod of intensifiedtight glycemic control, which may include multipledaily injections of insulin, insulin pump therapy and usage ofpramlintideSymlin™ and vitamin D therapy in dosages of 1000-2000 IUdayto maintain a 25-hydroxvitamin D level above 40 ngml.

Practice of the methods of the invention can involve multiple rounds, or“cycles,” of treatment. For example, an administration of an agent thatstimulates islet differentiation from progenitor cells together with anadministration of an agent that blocks autoimmune cells that targetpancreatic beta cells can be viewed as one cycle of the method of theinvention that involves co-administration of both types of agents.Alternatively, each administration of an islet differentiation agent canbe viewed as a cycle of treatment, and if an autoimmune cell blockingagent is administered, it may be administered in only a subset of suchcycles, or after the last administration of the islet differentiationagent. For example, only two DIAMYD™ injections of aluminum formulatedhuman recombinant GAD65 delivered 4 weeks apart subcutaneously to staveoff further beta cell destruction in patients with autoimmune diabetes(Agardh et al., J Diabetes Complications. 2005; 19(4):238-46). Whereas,a single course of anti-CD3 monoclonal antibody hOKT3gamma1(Ala-Ala)results in improvement in C-peptide responses and clinical parametersfor at least 2 years after onset of type 1 diabetes the anti-CD3antibody therapy (Herold, et al, Diabetes. 2005; 54(6):1763-9). Thus,depending on the selected immune blocker, the cyclicity of therapy mayvary to protect new islets from immune attack. It will be understoodthat the above examples are for illustration only and not intended tolimit the invention in any fashion. Those of skill in the art will alsoappreciate that, in many cases, the schedule of co-administration maydiffer in the first or a later therapeutic cycle for the convenience ofthe patient.

The combination therapies and related methods of the invention uniquelytarget the underlying pathologic mechanisms of type 1 diabetes withagents that regenerate new islet structures andor differentiatepancreatic progenitor cells in combination with agents that providetargeted immune therapy. This combination therapy reverses, wholly orpartially, the underlying mechanisms of type 1 diabetes, which is anautoimmune phenomenon in which anti-self antibodies attack the pancreas.Current therapies for type 1 diabetes that rely on the administration ofinsulin do not reverse the underlying defects in type 1 diabetes.Moreover, current immune therapies for type 1 diabetes based are basedupon rejection of pancreatic beta cells and do not impact thedifferentiation of new fully functional islet structures containing newalpha, beta, delta, and polypeptide cells within each new islet.

Among patients with type 2 diabetes, an immune blocking agent will notbe necessary since the basis of the disease is not immune destruction,although recent studies have pointed to a potentially important role ofvitamin D deficiency in type 1 diabetes and a recent study found that atthe time of diagnosis, more patients with type 2 diabetes are vitamin Ddeficient than type 1 diabetes and maintaining levels above 40 ngml arerecommended to maintain normal immune function (Riachy Apoptosis. 2006February; 11(2):151-9. Holick. Mayo Clin Proc. 2006 March; 81(3):353-73,Grant. Prog Biophys Mol Biol. 2006 Feb. 28; [Epub ahead of print].DiCesar. Diabetes Care. 2006 January; 29(1):174, Reis. Diabetes Metab.2005; 31(4 Pt 1):318-25, Pozzilli. Horm Metab Res. 2005; 37(11):680-3).No adverse effects have been seen with dosages up to 10,000 IUday(Heaney. Am J Clin Nutr, 204-210, Vieth. Am J Clin Nutr. 2001;73:288-294).

The new methods provided by the present invention reverse the underlyingpathologic mechanisms of type 2 diabetes and diseases and conditionsresulting from decreased insulin production due to an imbalance betweendestruction, regeneration, and sustenance beta cells via thedifferentiation of new islet structures, which contain fully functionalnew beta cells. The methods and compounds of the invention can reducethe insulin and diabetes medication requirements of patients currentlytaking the drug due to having type 2 diabetes or another disease orcondition and can improve glucose control in such patients. In somepatients, treatment in accordance with the methods of the invention canameliorate or obviate the need for administered insulin. The followingsection describes a variety of diseases and conditions that the methodsand compositions of the present invention can be used to treat withtherapeutic benefit.

Diseases and Conditions Amenable to Treatment

The HIP or HIP analog or derivative therapies or combination therapiesof the present invention can be used to treat any mammal, includinghumans and animals, suffering from a disease, symptom, or conditionrelated to a diminished production or secretion of insulin due to theloss of or diminished beta cell function or the need for greater insulinproduction than can be provided to the subject via differentiation ofnew islet structures from progenitor cells utilizing HIP compounds andmethods of treatment.

Such diseases and conditions include type 1 diabetes mellitus, type 2diabetes, pre-diabetes, impaired fasting glucose, fastinghyperinsulinemia, including but not limited to patients with type 1adiabetes patients or patients with Latent Autoimmune Diabetes ofAdulthood who may manifest antibodies (anti-GAD65 antibodies, anti-isletantibodies, or anti-insulin antibodies) or those patients with type 1diabetes with insulin deficiency without autoimmunity directed towardthe beta cells (type 1b diabetes). Moreover, the present invention canbe practiced with therapeutic benefit for patients newly diagnosed ashaving type 1 diabetes, the siblings and first degree relatives ofpatients with type 1 diabetes, and people with positive antibodies andother autoimmune conditions that indicate a predilection to type 1diabetes. In one embodiment, the methods of the invention are practicedto reverse type 1 diabetes in a patient in need of such treatment.

The combination therapies and related methods and compositions of theinvention can also be employed as adjunctive therapy to insulin therapyin type 1 diabetes in children and adults, to ameliorate glucose swingsin patients with diabetes, and in patients with poorly controlleddiabetes, hypoglycemic unawareness, and recurrent hypoglycemia in type 1diabetes.

The HIP or HIP analog or derivative therapies and related methods andcompositions of the invention can be used to treat patients having newlydiagnosed type 2 diabetes, type 2 diabetes in children and adults withhyperglycemia, type 2 diabetes being concurrently treated with insulin,oral diabetic or other subcutaneous diabetic therapies, and poorlycontrolled type 2 diabetes. In some patients, both children and adults,the methods and compositions of the invention can reverse type 1 and 2diabetes. The methods and compositions of the invention can also be usedto treat both children and adults having atypical forms of diabetes andpatients having the conditions of postprandial hyperglycemia.

The HIP or HIP analog or derivative therapies and related methods andcompositions of the invention can also be used to treat patients who arechildren, as well, as adult patients, in need of weight loss, reductionin triglycerides, LDL cholesterol, including but not limited to achieveweight loss or treat obesity, overweight in patients having diabetes aswell as those who do not have type 1 or 2 diabetes. In one embodiment,the methods and compositions of the invention are used to treat apatient having morbid obesity. In other embodiments, the methods andcompositions of the invention are used to treat a patient having morbidobesity or patients having anorexia, bulimia, or other eating disorders.

The single agent therapies and related methods and compositions of theinvention can also be used to treat children and adults havingdysmetabolic syndrome or metabolic syndrome, as well as patientsexhibiting the conditions of neuropathic pain syndromes secondary toaltered glucose metabolism, and those with hypertriglyceridemia with andwithout diabetes, and postprandial hypertriglyceridemia. In oneembodiment, these methods are practiced to treat polycystic ovariansyndrome in a patient in need of such treatment.

Other patients that can benefit from the HIP or HIP analog or derivativetherapies and related methods of the invention include children andadult patients diagnosed as having conditions such as fastinghyperglycemia, pre-diabetes, impaired fasting glucose, impaired glucosetolerance, and hyperglycemic conditions generally.

The HIP or HIP analog or derivative therapies and related methods andcompositions of the invention can also be used to treat patients havingneuropathic pain syndromes and neuropathy, regardless of whether thepatient is diagnosed as diabetic.

The HIP or HIP analog or derivative therapies and related methods andcompositions of the invention can also be used to treat patients havingrecurrent pancreatitis or pancreatic cancer and can be used in allmodalities aimed at achieving new islet structures derived fromprogenitor cells in the pancreas.

The following sections describe the agents useful in the methods of theinvention. Those of skill in the art will appreciate, in view of thedisclosure herein, that the skilled artisan may select particular agentsbased on the disease and condition being treated and the health andmedical status of the patient.

Agents for Stimulating Pancreatic Islet Regeneration

In one embodiment of the methods of the invention, the agent thatstimulates islet differentiation from pancreatic progenitor cells intoinsulin producing islet structures is selected from the group consistingof HIP or an analog or derivative thereof including glutamate-less HIP,tryptophan-HIP, valine-trypyophan HIP, hexapeptide HIP, septapeptideHIP, second septapeptide HIP or tryptophan-glutamate-less HIP, amylinandor an analog, including but not limited to Pramlintide (SYMLIN™),GLP-1 receptor analogs, exendin-4 (EXENATIDE™), Liraglutide (NN2211),GLP-1, GLP-1 analogs GIP, GLP-1, hamster INGAP, other incretin-mimetichormones, andor similarly acting compounds and agents, and agents thatextend the half-life or increase the level or activity of any of theforegoing compounds and agents, such as, for example, dipeptidylpeptidase-4 inhibitors, which delay the degradation of GLP-1. There arenumerous GLP-1 mimetics that act via direct agonist activity on theGLP-1 receptors or by inhibiting the degradation of GLP-1. These agentsare useful in the methods of the invention. GLP-1 mimetics can be usedin conjunction with HIP andor targeted immune therapy for the treatmentof type 1 diabetes, and, as provided by the present invention, they canbe used to improve glycemic control, increase satiety, delay gut glucoseabsorption and lead to a reversal of the underlying mechanisms resultingin type 1 diabetes. These agents and methods may prevent progression ofimpaired glucose tolerance in diabetes; to prevent pre-diabetes,progression of impaired fasting glucose to impaired glucose toleranceand diabetes; to reverse newly diagnosed type 2 diabetes; to treat type2 diabetes, and to treat or prevent overweight, obesity, polycysticovarian syndrome, and neuropathic pain syndromes.

Methods, agents, and pharmaceutical formulations useful in the practiceof the present invention to achieve pancreatic islet differentiationfrom progenitor cells in the adult pancreas and include those describedin the following references, each of which is incorporated herein byreference: Rosenberg et al., 1992, Adv. Exp. Med. Biol. 321: 95-104;March 1996, Diabetologia 39(3):256-62; July 1996, Pancreas 13(1):38-46;and November 2004, Ann. Surg. 240(5):875-84; Vinik et al., June 1997,Horm. Metab. Res. 29(6):278-93. The stimulation of islet regeneration ordifferentiation of pancreatic progenitor cells can be shown through theincreased production andor secretion of insulin in a subject.

In one embodiment of the invention, amylin or its analog, Symlin™pramlintide is employed prior to administration or in concomitantadministration with HIP, amylin may be administered prior to isletregeneration and continued through the islet regeneration periodadministration in accordance with the teachings of the reference Younget al., 1997, Curr. Opin. Endocrin. Diabetes 4: 282-290, incorporatedherein by reference. In one embodiment of the invention, amylin andor ananalog, including but not limited to Pramlintide, is administeredsubcutaneously to optimize glycemic control prior to the initiation ofHIP and may then be and used alone or in conjunction with other isletstimulating peptides, such as HIP or a HIP analog or derivative. In oneembodiment, amylin or Pramlintide is dosed at 0.3-0.8 micrograms perkilogram patient weight. In one embodiment, this dose is administeredsubcutaneously before meals, for example, QHS and 3 AM. In oneembodiment, the therapeutically effective dose is deliveredsubcutaneously or via an infusion devicepump andor a transdermal,intranasal, buccal, microneedle delivery system, oral encapsulationmethod. In another embodiment, the therapeutically effective dose isadministered utilizing sustained release formulations requiringadministration by injection or other delivery method no more frequentlythan once a week, once every 2 weeks, or once monthly. As noted above,in some embodiments, amylin or Pramlintide is co-administered withanother islet stimulating agent.

In one embodiment of the invention, a GLP-1 receptor analog, includingexendin-4 or an analog is employed in the method with HIP at dosages of5-10 mcg with meals. Exendin-4 can be formulated and administered forpurposes of the present invention in accordance with the teachings ofthe following references, each of which is incorporated herein byreference: Alcantara et al., 1998, Cell Biochem. Funct. 16(1): 51-6;Dupre et al., 2004, J. Clin. Endocrin. Metab. 89(7): 3469-73; Edwards etal., 1999, Diabetes 48: 86-93; and Xu et al., 1999, Diabetes 48:2270-76. In one embodiment, exendin-4 is dosed in the range of 5-10micrograms before meals. In one embodiment, exendin-4 is administeredsubcutaneously alone or in conjunction with HIP andor other isletstimulating peptides. In one embodiment, the therapeutically effectivedose is administered subcutaneously. In another embodiment, delivery ofexendin-4 is via transdermal, buccal, oral encapsulation methods,intranasal or microneedle delivery systems. In another embodiment, thetherapeutically effective dose is contained in a sustained releaseformulation that requires administration no more frequently than once aweek, once every 2 weeks, or once monthly. In one embodiment, exendin-4is co-administered with HIP or another islet cell neogenesis orprogenitor cell transformation agent among patients with type 1 or 2diabetes, or those with obesity, overweight, insulin resistant syndrome,impaired fasting glucose, pre-diabetes, polycystic ovarian syndrome, themetabolic syndrome or eating disorders.

GIP and GLP-1 belong to the incretin family of growth hormones (see thereferences Creutzfeldt, 1979, Diabetologia 16: 75-85; Creutzfeldt andEbert, 1985, Diabetologia 28: 565-573; Holst et al., 2001, Scand. J.Clin. Lab. Invest. Suppl. 234: 75-85; and Vilsboll et al., June 2003, J.Clin. Endocrin. Metab.88(6):2706-13, each of which is incorporatedherein by reference), and in one embodiment of the invention, anincretin hormone or analog with or without the concomitant usage of HIPis employed in the method to stimulate differentiation to islets fromprogenitor cells in the adult pancreas.

In one embodiment of the invention, GIP or an analog is employed with orwithout HIP. GIP can be formulated and administered for purposes of thepresent invention in accordance with the teachings of the followingreferences, each of which is incorporated herein by reference: Andersenet al., 1978, J. Clin. Invest. 62: 152-161; Creutzfeldt et al., February1980, Diabetes 29(2):140-5; Dupré et al., 1973, J. Clin. Endocrin.Metab. 37: 826-828; Ebert et al., 1980, Clinical Gastroenterology 9(3):679-98; Elahi et al., 1979, Am. J. Physiol. 237: E185-E191, and 1994,Regulatory Peptide 51(1): 63-74; Krarup et al., June 1983, J. Clin.Endocrin. Metab. 56(6):1306-12; Krarup et al., 1987, Metabolism 36(7):677-82; Krarup et al., 1988, Acta Med. Scand. 223(5):437-41; Lynn etal., 2003, FASEB 17:19-93; Meir et al., 2002, Regulatory Peptides107:1-3; and Nauk et al., 1993, J. Clin. Endocrin. Metab. 76(4): 912-7.

In one embodiment, GIP is administered intravenously or subcutaneouslyin combination with HIP or an analog or derivative thereof and dosed at2-10 nanograms per kilogram patient weight to provide a 30-minutecontinuous infusion by either intravenous or subcutaneous delivery timebeginning 3-5 minutes before meals, before bedtime, and beginning at 3AM. In one embodiment GIP is administered subcutaneously before meals,QHS, and 3 AM. In one embodiment, GIP is administered orally or using aninfusion device or a transdermal, buccal, intranasal or microneedledelivery systems. In another embodiment, a sustained release formulationrequiring administration no more frequently than once every week, onceevery 2 weeks, or once monthly injections is employed. Suitablecompositions for administering GIP in accordance with the methods of theinvention are described in the reference Jones et al., 6 Nov. 1989,Diabetes Res. Clin. Pract. 7(4):263-9.

In one embodiment of the invention, GLP-1 or an analog, or GLP-1receptor agonist or Dipeptidyl Peptidase-4 Inhibitor is employed incombination with HIP or an analog or derivative thereof, in the methodto stimulate islet differentiation from progenitor cells, GLP-1, GLP-1receptor agonists, GLP-1 analogs and DPP-4 inhibitors can be formulatedand administered for purposes of the present invention in accordancewith the teachings of the following references, each of which isincorporated herein by reference: Elahi et al., 1994, RegulatoryPeptides 51(1): 63-74; Gutniak et al., 1994, Diabetes Care 17:1039-44;Kreymann et al., 1987, Lancet 2: 1300-1304; Larsen et al., 1996,Diabetes 45(Suppl. 2):233A (Abstract); Larsen et al., 2001, DiabetesCare 24(8): 1416-21; List et al., 2004, Am. J. Physiol. Endocrin. Metab.286(6): E875-81; Lugari et al., 2000, Horm. Metab. Res. 32: 424-428;Marquez et al., March 1998, Cell. Biochem. Funct. 16(1):51-6; Meier etal., March 2004, Critical Care Medicine 32(3):848-851; Meneilly et al.,2003, Diabetes Care 26: 2835-41; Nauk et al., 1996, Diabetologia39(12):1546-53; Thorens et al., December 1995, DiabetesMetab.21(5):311-8; Vilsboll et al., 2003, J. Clin. Endocrin. Metab.88(6): 2706-13; Wang et al., 1997, J. Clin. Invest. 99: 2883-2889; andZander et al., 2002, Lancet 359: 824-30.

In one embodiment, GLP-1, GLP-1 receptor agonists, GLP-1 analogs isadministered subcutaneously or DPP-4 inhibitors are given orally incombination with HIP or an analog or derivative thereof and dosed in therange of 400-800 mg per day at 8-20 mg per kilogram patient weight. Inone embodiment GLP-1 is administered orally or subcutaneously beforemeals, QHS. In one embodiment, GLP-1 is administered using a continuoussubcutaneous infusion device at a rate of 1-30 ngkilogram bodyweightminute or a transdermal, buccal, or microneedle delivery system toprovide a 30-minute continuous infusion by either intravenous orsubcutaneous delivery time beginning 3-5 minutes before meals, beforebedtime, and beginning at 3 AM. In another embodiment, a sustainedrelease formulation requiring administration no more frequently thanonce every week, once every 2 weeks, or once monthly injections isemployed.

In one embodiment, a non-humanhamster INGAP is administeredsubcutaneously in combination with HIP or an analog or derivativethereof and dosed at 5.0-20.0 milligrams per kilogram patient weight perbody weight per day. In another embodiment, the hamster INGAP isadministered in a continuous subcutaneous infusion over 24 hours. Inanother embodiment, the hamster INGAP is administered in divided dosagespr day before meals, QHS. In another embodiment, the hamster INGAP isadministered using a continuous infusion by either intravenous orsubcutaneous delivery device, continuous infusion via pump, transdermalpatch, oral encapsulation method, microneedle delivery system to providea consistent basal level delivery of hamster INGAP. In anotherembodiment, the hamster INGAP is delivered in a continuous infusion byeither intravenous or subcutaneous delivery with bolus delivery beforemeals. In another embodiment, a sustained release formulation requiringadministration no more frequently than once every week, once every 2weeks, or once monthly injections is employed.

In one embodiment, Liraglutide (NN2211) is administered subcutaneouslyin combination with HIP or an analog or derivative thereof in dosages of10-40 micrograms per kilogram body weight. In another embodimentLiraglutide is administered subcutaneously before meals, QHS, and 3 AM.In another embodiment, Liraglutide is administered using an infusiondevice or a transdermal, buccal, or microneedle delivery system toprovide a 30-minute continuous infusion by either intravenous orsubcutaneous delivery time beginning 3-5 minutes before meals, beforebedtime, and beginning at 3 AM. In another embodiment, a sustainedrelease formulation requiring administration no more frequently thanonce every week, once every 2 weeks, or once monthly injections isemployed.

In the combination therapies of the invention, Liraglutide or NN2211 isadministered at a dose of about 20 micrograms per kg of patient weightdaily. This dose will provide patients the ability to reduce bolusinsulin before meals by 10-20% with reduced fluctuations and decreasedpostprandial glucose, glucagon, and triglycerides. Administration ofLiraglutide in accordance with the methods of the invention can be usedto improve glycemic control, as measured, for example and withoutlimitation, by hemoglobin A1C, in type 1 diabetes; to preventprogression of impaired glucose tolerance in diabetes; to preventprogression of impaired fasting glucose to impaired glucose toleranceand diabetes; to reverse newly diagnosed type 2 diabetes; and to treattype 2 diabetes.

In an embodiment of the combination therapy of the invention,Liraglutide or NN2211 is administered at a dose of about 20 microgramsper kg of patient weight to an adult patient in the morning, about 4hours before food intake, and at bedtime for three consecutive weeks.For patients initiating treatment with C-peptide levels lower than about1.0 ngmL, C-peptide levels are monitored, and when they rise above 0.5ngmL, the antibody hOKT3g1 (ala-ala) is administered for 12 consecutivedays.

In the combination therapies of the invention, exendin-4 or syntheticexendin-4 or another GLP-1 analog, GLP-1 receptor agonist, or DipeptidylPeptidase-4 Inhibitor is administered prior to meals alone or with HIPor another islet differentiation agent to improve glycemic control priorto or during the initiation of HIP therapies. Such agents, whendelivered prior to meals may result in a reduction in the need forinsulin of at least 20% and appropriate tapering of insulin and diabeticmedications will be conducted while HIP or other islet differentiationagent is given (Levetan et al., Diabetes Care 2003 January; 26(1):1-8).As HIP andor other agents are delivered in both type 1 and type 2patients, careful taper of insulin and diabetes medications will takeplace to protect against hypoglycemia as new islet cells aredifferentiated from progenitor cells. Ultimately, insulin and diabetesmedications, including HIP will be tapered off as the pancreas isrepopulated with new functional islet cells. For patients initiatingtreatment with C-peptide levels lower than about 1.0 ngmL, C-peptidelevels are monitored, and when they rise above 0.5 ngmL, carefulmonitoring and tapering of exogenous insulin dosages will occur.

Among patients with type 1 diabetes, prior to initiation of HIP andorother peptide compounds (SYMLIN™, hamster INGAP, GLP-1, GLP-1 receptoragonists, GLP-1 analogs, DPP-4 inhibitors are used with (preceding,during, or following) immune therapy will be administered to protectnewly formed islets. For example, the antibody hOKT3g1 (ala-ala) isadministered for 12 consecutive days with its efficacy demonstratedfollowing the first treatment out to 24 months, whereas a similarhumanized monoclonal antibody, ChAglyCD3 may be administered for 6consecutive days, then repeated yearly. Diamyd's GAD65 compound isdelivered in two subcutaneous injections, one month apart. DIAPEP277™, aheat shock protein 60, has demonstrated success among newly diagnoseddiabetes patients utilizing a subcutaneous injections of 1 mg with 40 mgmannitol in vegetable oil at study entry, 1 month, and 6 months, Basedupon the immune modulator selected, the cyclicity of treatment will bedetermined. In another embodiment, DIAPEP277™, a heat shock protein 60vaccine, DIAPEP277™, and IBC-VSO vaccine, which is a synthetic,metabolically inactive form of insulin designed to prevent pancreaticbeta-cell destruction, interferon-alpha, or vaccination using CD4⁺CD25⁺antigen-specific regulatory T cells or a similar agent is used in thecombination therapy. In another embodiment, approaches utilizingimmunomodulation including, but not limited to use of anti-CD3immunotherapy are used, which include: Sirolimus (Rapamycin), Tacrolimus(FK506), a heat-shock protein 60 (DIAPEP277™), anti-Glutamic AcidDecarboxylase65 (GAD65) vaccine, Mycophenolate Mofetil alone or incombination with Daclizumab, the anti-CD20 agent Rituximab, Campath-1H(Anti-CD52 Antibody) andor Vitamin D used alone or in the combinationwith therapy approaches to utilizing regulatory T cells either directlyor through the use of anti-CD3 immunotherapy.

Agents that Inhibit, Block, or Destroy the Autoimmune Cells that TargetCells within Pancreatic Islet Structures

Autoimmune cells that target pancreatic beta cells and, play a causativerole in at least some of the diseases and conditions treatable inaccordance with the methods of the invention. See the references Bach etal., 2001, Ann. Rev. Immun. 19: 131-161; Lernmark et al., Endocrin.Metab. Clin. N. Am. 20(3): 589-617; and Mathis et al., December 2001,Nature 414(6865): 792-798, each of which is incorporated herein byreference.

Prior methods of treatment involving the introduction of immune agentsamong patients with type 1 diabetes, protect only those islet cellswhich have yet been destroyed by immune attack and do not address toneed to repopulate the pancreas with new islet structures with fullyfunctionally beta cells. These methods combine generalized and specificimmune modulation aimed at reducing destruction of beta cells and amethodology of differentiating new islet cells from progenitor cellswithin the adult pancreas.

The methods of the present invention may employ agents that specificallyinhibit the activity of or block or destroy the autoimmune cells thattarget pancreatic beta cells that produce insulin, amylin, or glucagon.Such agents include immunomodulatory peptides that arrest pancreaticislet cell destruction. For example, one such agent is a monoclonalantibody that can delay the progression of islet cell loss or slow orstop the onset of type 1 diabetes. Anti-CD3 antibodies constitute ageneral class of agents useful in the methods of the invention. Forexample, suitable anti-CD3 antibodies for purposes of the presentinvention include the TRX4 (Ala-Ala and ChAglyCD3) antibody underdevelopment by TolerRx and the humanized anti-CD3 antibody described inthe reference Herold et al., 30 May 2002, NEJM 346(22):1692-1698,incorporated herein by reference. In one embodiment, the humanizedanti-CD3 antibody is delivered intravenously, 14 days per year in thedosage of 1-1.42 μgkg on day 1, 5.67 μgkg on day 2, 11.3 μgkg on day 3,22.6 μgkg on day 4 and 45.4 μgkg on days 5-14. These therapies may berepeated annually following the 3-6 month usage of HIP, while insulin isbeing tapered as new islet cell formation occurs. During the HIPtreatment phase, Vitamin D and the usage of pramlintideSymlin™ may becontinued. Following the discontinuation of HIP and insulin therapy,immune modulation may be repeated annually for the anti-CD3 antibodies,though recent study has found their efficacy to continue for as long as24 months (Herold. Diabetes. 2005; 54(6):1763-9).

In another embodiment, the immuno-modulatory compound is a heat shockprotein that can arrest or slow islet cell destruction. Such proteinsinclude DIAPEP277™, a heat-shock protein under development by DevelogenAG (see the reference Raz et al., 2002, Lancet 358(9295):1749-53,incorporated herein by reference). In one embodiment, DIAPEP277™ isdelivered subcutaneously by giving 1 mg in 40 mg mannitol in vegetableoil subcutaneously at baseline and at one month and then twice at 3month intervals. In one embodiment of the combination therapy of theinvention, HIP or a HIP analog or derivative is co-administered withDIAPEP277™ as follows. The DIAPEP277™ is first administeredsubcutaneously at a dose of about 1 mg, about 30 days prior to theinitiation of the HIP or analog or derivative-based therapy. A secondadministration of the DIAPEP277™ is then made at the time (90 days afterthe first administration) of initiating the HIP or analog orderivative-based therapy.

The HIP or analog or derivative thereof may be delivered viasubcutaneous injection, orally via hepatic targeted vesicle, or otherliposomal agent, or via 24 hour continuous subcutaneous infusion at adose of about 5 to 20 mg per kg of patient body weight per 24 hours sothat the dosage per day is ˜600-800 mgday per patient. The HIP or analogor derivative-based therapy is continued for a 3-6 month period andmonitored closely by C-peptide production. The immune therapy will bedelivered cyclically based upon the immune agent selected. For example,the DIAPEP277™ is administered at 3 month intervals for a total of 6months, and would initially be delivered 3 months prior to HIP or analogor derivative-based therapy (Raz et al., Lancet. 2001 Nov. 24;358(9295):1749-53).

The immuno-modulatory agents useful in the methods of the invention canbe formulated, administered, and dosed as known in the art or asdescribed herein. Pharmaceutical formulations and additional dosing andadministration protocols for practice of the methods of the inventionare described below.

AdditivitySynergy

Compositions of HIP or an analog or derivative thereof, e.g.,glutamate-less HIP, tryptophan-HIP, valine-trypyophan HIP, hexapeptideHIP, septapeptide HIP, second septapeptide HIP ortryptophan-glutamate-less HIP, and pharmaceutically acceptable salts andesters thereof are synergistically or additively effective todifferentiate progenitor cells into new islet cells in treating diabetesor a similar disorders when combined with various other compounds. Thesecompounds include HIP and analogs or derivatives thereof, amylin andoran analog, including but not limited to SymlinPramlintide, GLP-1, GLP-1receptor agonists, such as exendin-4, Liraglutide (NN2211), GLP-1analogs, Dipeptidyl Peptidase-4 Inhibitors, GIP, hamster INGAP, andother incretin-mimetic hormones, andor similarly acting compounds andagents, and agents that extend the half-life or increase the level oractivity of any of the foregoing compounds and agents, such as, forexample, dipeptidyl peptidase inhibitors, which delay the degradation ofGLP-1, and agents that inhibit, block, or destroy the autoimmune cellsthat target beta cells including but not limited to: anti CD-3antibodies (hOKT3γ1 Ala-Ala and ChAglyCD3), Sirolimus (Rapamycin),Tacrolimus (FK506), a heat-shock protein 60 (DIAPEP277™) a anti-GlutamicAcid Decarboxylase 65 (GAD65) vaccine, Mycophenolate Mofetil alone or incombination with Daclizumab, the anti-CD20 agent Rituximab, Campath-1H(Anti-CD52 Antibody), lysofylline, and Vitamin D, IBC-VSO vaccine whichis a synthetic, metabolically inactive form of insulin designed toprevent pancreatic beta-cell destruction, and interferon-α vaccinationusing CD4⁺CD25⁺ antigen-specific regulatory T cells or a similar agentdesigned to prevent pancreatic beta-cell destruction. In this lastembodiment, interferon-α vaccination using CD4⁺CD25⁺ antigen-specificregulatory T cells or a similar agent is used in the combination therapyfor utilizing regulatory T cells either directly or through the use ofanti-CD3 immunotherapy.

Compounds such as Sirolimus (Rapamycin), Tacrolimus (FK506), TRX4antibody, humanized anti-CD3 antibody, DYAMID™ anti-GAD65 antibody, andDIAPEP277™ are also synergistically or additively effective when addedto usage of HIP or an agent to differentiate progenitor cells into newislet cells in treating diabetes or a similar disorders.

Synergy is defined as the interaction of two or more agents so thattheir combined effect is greater than the sum of their individualeffects. For example, if the effect of drug A alone in treating adisease is 25%, and the effect of drug B alone in treating a disease is25%, but when the two drugs are combined the effect in treating thedisease is 75%, the effect of A and B is synergistic.

Additivity is defined as the interaction of two or more agents so thattheir combined effect is similar to the average of their individualeffects. For example, if the effect of drug A alone in treating adisease is 25%, and the effect of drug B alone in treating a disease is25%, but when the two drugs are combined the effect in treating thedisease is about 50% or at least greater than 25%, the effect of A and Bis additive.

An improvement in a drug therapeutic regimen can be obtained by thecombined administration of two agents having therapeutic effect, if theinteraction of the two or more agents is such that their combined effectreduces the incidence of adverse event (AE) of either or both agentsused in the co-therapy. This reduction in the incidence of adverseeffects can be a result of, e.g., administration of lower dosages ofeither or both agent used in the co-therapy. For example, if the effectof drug A alone is 25% and has an adverse event incidence of 45% whenused at the labeled dose; and the effect of drug B alone is 25% and hasan adverse event incidence of 30% when used at the labeled dose, butwhen the two drugs are combined at lower than labeled doses of each, ifthe overall effect is 35% and the adverse incidence rate is 20%, thereis an improvement in the drug therapeutic regimen. The combinationtherapies provided by the present invention include those exhibitingsuch improvements.

Pharmaceutical Compositions, Dosing and Administration

Dosing and administration of the agents useful in the methods of theinvention as described herein provide accelerated islet differentiationfrom adult progenitor cells to optimize an individual's ability tosecrete insulin from endogenous, newly formed islet structures with usedin conjunction with immune therapy or therapies, which give the lowesttoxicity while providing protection of the new islets from destruction.Pharmaceutical compositions of the invention provide for kineticdelivery of these agents, ease of delivery, and enhanced efficacy.

In one embodiment, HIP peptide would be dosed subcutaneously, betweenabout 20-2000 mg, (0.02857 to 285.7 mgkg) four times daily,pre-prandially, before each meal and a dose at bedtime. In anotherembodiment, HIP peptide is dosed at about 200 mg (2.857 mgkg) four timesdaily, pre-prandially, before each meal and a dose at bedtime.

Preferably HIP peptide would be dosed at 10-15 mgkg delivered in fourseparate subcutaneous injections for a total of approximately 800 mgdaytotal per day.

HIP Peptide may be administered as few times as once daily and as manytimes as 20 times daily or by continuous infusion.

The agents useful in the methods of the invention can be administered bya variety of routes. Known agents useful in the methods of the inventioncan be administered by routes and using pharmaceutical formulationspreviously developed for other indications. Such delivery routesinclude, at least for most known agents, oral delivery, targeted anduntargeted liposomal drug delivery systems for oral or subcutaneousdelivery, which may include the hepatic-directed vesicle (AMDGSDG)attached to HIP or compounds used in the methodologies described herein,topical delivery, including micelle and nanosphere topical deliverysystems, subcutaneous delivery including pump-assisted continuousinfusion by either intravenous or subcutaneous delivery and disposablemicro-pumps and micro-needles (including but not limited to thoseavailable from Animas Corp.), and buccal delivery.

The particular route of administration and pharmaceutical formulation ofan agent used in the practice of the methods of the invention will beselected by the practitioner based on a patient's disease or conditionbeing treated and the agent employed. A wide variety of pharmaceuticalcompositions can be employed in the methods of the invention. In someembodiments, extended use preparations can be used for ease ofadministration and increased efficacy.

In one embodiment, one or more of the agents employed in the method isformulated as a micelle. Often, ease of administration is best achievedby oral delivery. While small molecule pharmaceutical agents can oftenbe readily formulated for oral delivery, peptide and protein-basedpharmaceutical agents can be more difficult to formulate for oraldelivery. However, suitable formulation technology exists, and in oneimportant aspect, the present invention provides pharmaceuticalcompositions of proteins and peptides formulated for oral delivery. Inone embodiment, the pharmaceutical compositions useful in the methods ofthe invention suitable for oral delivery are formulated generally inaccordance with known TECHNOSPHERE™ technology developed by MannKindCorp., ELIGEN® Technology developed by Emisphere, a nasal deliverysystems developed by Nastech, an oral liposome with specificity to theliver (HDV) developed by AMDGSDG).

Other oral delivery and encapsulation technology suitable for use inmaking the pharmaceutical compositions of the invention includes thehepatic delivery vesicle (HDV). Pancreatic delivery vesicle (PDV)technology has been proposed by CureDM to SDGAMDG for potential usage indelivery of compounds described in the methods herein. HDV technologycan be used to deliver compounds in the methodology herein including HIP(Davis et al., 2001, J. Diabetes Comp. 15(5): 227-33) and GLP-1 directlyto the liver. PDV technology provides liposomes with a conjugatedprotein or other molecule on its surface that directs an agent, such asa peptide that stimulates islet cell neogenesis, directly to thepancreas.

Agents that can be formulated for oral delivery and employed in themethods of the invention include HIP or an analog or derivative thereofincluding glutamate-less HIP, tryptophan-HIP, valine-trypyophan HIP,hexapeptide HIP, septapeptide HIP, second septapeptide HIP ortryptophan-glutamate-less HIP, SYMLIN™pramlintide, Exendin-4,Liraglutide (NN2211), GLP-1 receptor agonists, GLP-1, GLP-1 analogs,hamster INGAP and its analogs, GIP, Dipeptydyl peptidase-4 inhibitorsand peptide and proteins or non-peptidic mimetics with similar action orhomology to the preceding agents used with monoclonal antibodies andother specific and general immune agents designed to delay theprogression of beta cell loss or prevent the onset of type 1 diabetes inboth children and adults, including, but not limited to anti CD-3antibodies (hOKT3γ1(Ala-Ala and ChAglyCD3) that target the immuneresponse and specifically block the T-lymphocytes that cause islet celldeath in type 1 diabetes, as well as, Sirolimus (Rapamycin), Tacrolimus(FK506), a heat-shock protein 60 (DIAPEP277™) an anti-Glutamic AcidDecarboxylase 65 (GAD65) vaccine, Mycophenolate Mofetil alone or incombination with Daclizumab, the anti-CD20 agent, Rituximab, Campath-1H(Anti-CD52 Antibody), lysofylline, Vitamin D, IBC-VSO vaccine which is asynthetic, metabolically inactive form of insulin designed to preventpancreatic beta-cell destruction, interferon-alpha. vaccination usingCD4⁺CD25⁺ antigen-specific regulatory T cells or a similar agent is usedin the combination therapy approaches to utilizing regulatory T cellseither directly or through the use of immunotherapy to arrest thedestruction of insulin-producing cells.

Kits

The invention further relates to kits for treating patients having type1 or type 2 diabetes or other glucose metabolism disorders in childrenand adults including pre-diabetes, impaired fasting glucose, insulinresistant syndromes, the metabolic syndrome, obesity, overweight,polycysistic ovarian syndrome, hyperlipidemia, hypertriglyceridemiacomprising one or more therapeutically effective methods of HIP or ananalog or derivative modes of treatment thereof (e.g., tryptophan HIP,glutamate-less HIP, valine-trypyophan HIP, hexapeptide HIP, septapeptideHIP, second septapeptide HIP or tryptophan-glutamate-less HIP).Optionally, the kit may also contain other agents (e.g.SYMLIN™pramlintide, exendin-4, GIP, GLP-1 receptor agonists, Liraglutide(NN2211), Exendin-4, GLP-1 analogs, hamster INGAP, or a dipeptidylpeptidase inhibitor) andor agents that inhibit, block, or destroy theautoimmune cells that target pancreatic islet cells including, but notlimited to but not limited to anti CD-3 antibodies (hOKT3γ1(Ala-Ala andChAglyCD3) that target the immune response and specifically block theT-lymphocytes that cause islet cell death in type 1 diabetes, as wellas, Sirolimus (Rapamycin), Tacrolimus (FK506), a heat-shock protein 60(DiaPep277) an anti-Glutamic Acid Decarboxylase 65 (GAD65) vaccine,Mycophenolate Mofetil alone or in combination with Daclizumab, theanti-CD20 agent, Rituximab, Campath-1H (Anti-CD52 Antibody),lysofylline, Vitamin D, IBC-VSO vaccine which is a synthetic,metabolically inactive form of insulin designed to prevent pancreaticbeta-cell destruction, interferon-alpha. vaccination using CD4⁺CD25⁺antigen-specific regulatory T cells or a similar agent is used in thecombination therapy approaches to utilizing regulatory T cells eitherdirectly or through the use of immunotherapy to arrest the destructionof insulin-producing cells, either in the same or separate packaging,and instructions for its use.

Antibodies to HIP and Analogs or Derivatives Thereof

In various embodiments, monoclonal or polyclonal antibodies specific toHIP or analogs or derivatives thereof can be used in immunoassays tomeasure the amount of HIP or analogs or derivatives thereof or used inimmunoaffinity purification of a HIP or analogs or derivatives thereof.A Hopp & Woods hydrophilic analysis (see Hopp & Woods, Proc. Natl. Acad.Sci. U.S.A. 78:3824-3828 (1981) can be used to identify hydrophilicregions of a protein, and to identify potential epitopes of a HIP oranalogs or derivatives thereof.

The antibodies that immunospecifically bind to an HIP or analogs orderivatives thereof can be produced by any method known in the art forthe synthesis of antibodies, in particular, by chemical synthesis orpreferably, by recombinant expression techniques. (See, e.g., U.S.Publication No. 20050084449, which is incorporated herein in itsentirety).

Polyclonal antibodies immunospecific for HIP or analogs or derivativesthereof can be produced by various procedures well-known in the art. Forexample, HIP or analogs or derivatives thereof can be administered tovarious host animals, including, but not limited to, rabbits, mice, andrats, to induce the production of sera containing polyclonal antibodiesspecific for HIP or analogs or derivatives thereof. Various adjuvantsmay be used to increase the immunological response, depending on thehost species, including but are not limited to, Freund's (complete andincomplete), mineral gels such as aluminum hydroxide, surface activesubstances such as lysolecithin, pluronic polyols, polyanions, peptides,oil emulsions, keyhole limpet hemocyanins, dinitrophenol, andpotentially useful human adjuvants such as BCG (bacille Calmette-Guerin)and corynebacterium parvum. Such adjuvants are also well known in theart.

Monoclonal antibodies can be prepared using a wide variety of techniquesknown in the art, including the use of hybridoma, recombinant, and phagedisplay technologies, or a combination thereof. For example, monoclonalantibodies can be produced using hybridoma techniques, including thoseknown in the art and taught, for example, in Harlow et al., Antibodies:A Laboratory Manual, (Cold Spring Harbor Laboratory Press, 2nd ed.1988); and Hammerling et al., in: Monoclonal Antibodies and T CellHybridomas 563 681 (Elsevier, N.Y., 1981). The term “monoclonalantibody” as used herein is not limited to antibodies produced throughhybridoma technology. The term “monoclonal antibody” refers to anantibody that is derived from a single clone, including any eukaryotic,prokaryotic, or phage clone, and not the method by which it is produced.

Methods for producing and screening for specific antibodies usinghybridoma technology are routine and well known in the art. Briefly,mice can be immunized with a non-murine antigen, and once an immuneresponse is detected, e.g., antibodies specific for the antigen aredetected in the mouse serum, the mouse spleen is harvested andsplenocytes isolated. The splenocytes are then fused by well knowntechniques to any suitable myeloma cells, for example cells from cellline SP20 available from the ATCC. Hybridomas are selected and cloned bylimited dilution. The hybridoma clones are then assayed by methods knownin the art for cells that secrete antibodies capable of binding apolypeptide of the invention. Ascites fluid, which generally containshigh levels of antibodies, can be generated by immunizing mice withpositive hybridoma clones.

The present invention provides methods of generating monoclonalantibodies as well as antibodies produced by the method comprisingculturing a hybridoma cell secreting an antibody of the inventionwherein, preferably, the hybridoma is generated by fusing splenocytesisolated from a mouse immunized with a non-murine antigen with myelomacells and then screening the hybridomas resulting from the fusion forhybridoma clones that secrete an antibody able to bind to the antigen.

Antibody fragments which recognize specific particular epitopes may begenerated by any technique known to those of skill in the art. Forexample, Fab and F(ab′)2 fragments of the invention may be produced byproteolytic cleavage of immunoglobulin molecules, using enzymes such aspapain (to produce Fab fragments) or pepsin (to produce F(ab′)2fragments). F(ab′)2 fragments contain the variable region, the lightchain constant region and the CH1 domain of the heavy chain. Further,the antibodies of the present invention can also be generated usingvarious phage display methods known in the art.

In phage display methods, functional antibody domains are displayed onthe surface of phage particles which carry the polynucleotide sequencesencoding them. In particular, DNA sequences encoding VH and VL domainsare amplified from animal cDNA libraries (e.g., human or murine cDNAlibraries of affected tissues). The DNA encoding the VH and VL domainsare recombined together with a scFv linker by PCR and cloned into aphagemid vector. The vector is electroporated in E. coli, and the E.coli is infected with helper phage. Phage used in these methods aretypically filamentous phage including fd and M13 and the VH and VLdomains are usually recombinantly fused to either the phage gene III orgene VIII. Phage expressing an antigen binding domain that binds to aparticular antigen can be selected or identified with antigen, e.g.,using labeled antigen or antigen bound or captured to a solid surface orbead. Examples of phage display methods that can be used to make theantibodies of the present invention include those disclosed in Brinkmanet al., 1995, J. Immunol. Methods 182:41-50; Ames et al., 1995, J.Immunol. Methods 184:177-186; Kettleborough et al., 1994, Eur. J.Immunol. 24:952-958; Persic et al., 1997, Gene 187:9-18; Burton et al.,1994, Advances in Immunology 57:191-280; International application No.PCTGB91O1 134; International publication Nos. WO 9002809; WO 9110737; WO9201047; WO 9218619; WO 9311236; WO 9515982; WO 9520401; and WO9713844;and U.S. Pat. Nos. 5,698,426; 5,223,409; 5,403,484; 5,580,717;5,427,908; 5,750,753; 5,821,047; 5,571,698; 5,427,908; 5,516,637;5,780,225; 5,658,727; 5,733,743; and 5,969,108.

As described in the above references, after phage selection, theantibody coding regions from the phage can be isolated and used togenerate whole antibodies or any other desired antigen binding fragment,and expressed in any desired host, including mammalian cells, insectcells, plant cells, yeast, and bacteria, e.g., as described below.Techniques to produce Fab, Fab′ and F(ab′)2 fragments recombinantly canalso be employed using methods known in the art such as those disclosedin PCT publication No. WO 9222324; Mullinax et al., 1992, BioTechniques12(6):864-869; Sawai et al., 1995, AJRI 34:26-34; and Better et al.,1988, Science 240:1041-1043.

To generate whole antibodies, PCR primers including VH or VL nucleotidesequences, a restriction site, and a flanking sequence to protect therestriction site can be used to amplify the VH or VL sequences in scFvclones. Utilizing cloning techniques known to those of skill in the art,the PCR amplified VH domains can be cloned into vectors expressing a VHconstant region, e.g., the human gamma 4 constant region, and the PCRamplified VL domains can be cloned into vectors expressing a VL constantregion, e.g., human kappa or lambda constant regions. Preferably, thevectors for expressing the VH or VL domains comprise an EF-1α promoter,a secretion signal, a cloning site for the variable domain, constantdomains, and a selection marker such as neomycin. The VH and VL domainsmay also be cloned into one vector expressing the necessary constantregions. The heavy chain conversion vectors and light chain conversionvectors are then co-transfected into cell lines to generate stable ortransient cell lines that express full-length antibodies, e.g., IgG,using techniques known to those of skill in the art.

For some uses, including in vivo use of antibodies in humans and invitro detection assays, it may be preferable to use humanized antibodiesor chimeric antibodies. Human antibodies can be made by a variety ofmethods known in the art including phage display methods described aboveusing antibody libraries derived from human immunoglobulin sequences.See also U.S. Pat. Nos. 4,444,887 and 4,716,111; and Internationalpublication Nos. WO 9846645, WO 9850433, WO 9824893, WO9816654, WO9634096, WO 9633735, and WO 9110741.

A chimeric antibody is a molecule in which different portions of theantibody are derived from different immunoglobulin molecules. Methodsfor producing chimeric antibodies are known in the art. See e.g.,Morrison, 1985, Science 229:1202; Oi et al., 1986, BioTechniques 4:214;Gillies et al., 1989, J. Immunol. Methods 125:191-202; and U.S. Pat.Nos. 5,807,715; 4,816,567; 4,816,397; and 6,311,415.

A humanized antibody is an antibody or its variant or fragment thereofwhich is capable of binding to a predetermined antigen and whichcomprises a framework region having substantially the amino acidsequence of a human immunoglobulin and a CDR having substantially theamino acid sequence of a non human immunoglobulin. A humanized antibodycomprises substantially all of at least one, and typically two, variabledomains (Fab, Fab′, F(ab′)2, Fabc, Fv) in which all or substantially allof the CDR regions correspond to those of a non human immunoglobulin(i.e., donor antibody) and all or substantially all of the frameworkregions are those of a human immunoglobulin consensus sequence.Preferably, a humanized antibody also comprises at least a portion of animmunoglobulin constant region (Fc), typically that of a humanimmunoglobulin. Ordinarily, the antibody will contain both the lightchain as well as at least the variable domain of a heavy chain. Theantibody also may include the CH1, hinge, CH2, CH3, and CH4 regions ofthe heavy chain. The humanized antibody can be selected from any classof immunoglobulins, including IgM, IgG, IgD, IgA and IgE, and anyisotype, including IgG1, IgG2, IgG3 and IgG4. Usually the constantdomain is a complement fixing constant domain where it is desired thatthe humanized antibody exhibit cytotoxic activity, and the class istypically IgG1. Where such cytotoxic activity is not desirable, theconstant domain may be of the IgG2 class. The humanized antibody maycomprise sequences from more than one class or isotype, and selectingparticular constant domains to optimize desired effector functions iswithin the ordinary skill in the art. The framework and CDR regions of ahumanized antibody need not correspond precisely to the parentalsequences, e.g., the donor CDR or the consensus framework may bemutagenized by substitution, insertion or deletion of at least oneresidue so that the CDR or framework residue at that site does notcorrespond to either the consensus or the import antibody. Suchmutations, however, will not be extensive. Usually, at least 75% of thehumanized antibody residues will correspond to those of the parentalframework region (FR) and CDR sequences, more often 90%, and mostpreferably greater than 95%. Humanized antibody can be produced usingvariety of techniques known in the art, including but not limited to,CDR grafting (European Patent No. EP 239,400; International PublicationNo. WO 9109967; and U.S. Pat. Nos. 5,225,539; 5,530,101; and 5,585,089),veneering or resurfacing (European Patent Nos. EP 592,106 and EP519,596; Padlan, 1991, Molecular Immunology 28(45):489 498; Studnicka etal., 1994, Protein Engineering 7(6):805 814; and Roguska et al., 1994,PNAS 91:969 973), chain shuffling (U.S. Pat. No. 5,565,332), andtechniques disclosed in, e.g., U.S. Pat. No. 6,407,213; U.S. Pat. No.5,766,886; WO 9317105; Tan et al., J. Immunol. 169:1119-25 (2002);Caldas et al., Protein Eng. 13(5):353-60 (2000); Morea et al., Methods20(3):267-79 (2000); Baca et al., J. Biol. Chem. 272(16):10678-84(1997); Roguska et al., Protein Eng. 9(10):895-904 (1996); Couto et al.,Cancer Res. 55 (23 Supp):5973s-5977s (1995); Couto et al., Cancer Res.55(8):1717-22 (1995); Sandhu J S, Gene 150(2):409-10 (1994); andPedersen et al., J. Mol. Biol. 235(3):959-73 (1994). Often, frameworkresidues in the framework regions will be substituted with thecorresponding residue from the CDR donor antibody to alter, preferablyimprove, antigen binding. These framework substitutions are identifiedby methods well known in the art, e.g., by modeling of the interactionsof the CDR and framework residues to identify framework residuesimportant for antigen binding and sequence comparison to identifyunusual framework residues at particular positions. (See, e.g., Queen etal., U.S. Pat. No. 5,585,089; and Riechmann et al., 1988, Nature332:323).

Methods of Preparing HIP and Analogs or Derivatives Thereof

Any techniques known in the art can be used in purifying HIP or ananalog or derivative thereof, including but not limited to, separationby precipitation, separation by adsorption (e.g., column chromatography,membrane adsorbents, radial flow columns, batch adsorption,high-performance liquid chromatography, ion exchange chromatography,inorganic adsorbents, hydrophobic adsorbents, immobilized metal affinitychromatography, affinity chromatography), or separation in solution(e.g., gel filtration, electrophoresis, liquid phase partitioning,detergent partitioning, organic solvent extraction, andultrafiltration). See e.g., Scopes, PROTEIN PURIFICATION, PRINCIPLES ANDPRACTICE, 3rd ed., Springer (1994). During the purification, thebiological activity of HIP or an analog or derivative thereof may bemonitored by one or more in vitro or in vivo assays. The purity of HIPor an analog or derivative thereof can be assayed by any methods knownin the art, such as but not limited to, gel electrophoresis. See Scopes,supra. In some embodiments, HIP or an analog or derivative thereofemployed in a composition of the invention can be in the range of 80 to100 percent of the total mg protein, or at least 80%, at least 85%, atleast 90%, at least 95%, or at least 98% of the total mg protein. In oneembodiment, HIP or an analog or derivative thereof employed in acomposition of the invention is at least 99% of the total protein. Inanother embodiment, HIP or an analog or derivative thereof is purifiedto apparent homogeneity, as assayed, e.g., by sodium dodecyl sulfatepolyacrylamide gel electrophoresis.

Methods known in the art can be utilized to produce HIP or an analog orderivative thereof recombinantly. A nucleic acid sequence encoding a HIPor an analog or derivative thereof can be inserted into an expressionvector for propagation and expression in host cells.

An expression construct, as used herein, refers to a nucleic acidsequence encoding a HIP or an analog or derivative thereof operablyassociated with one or more regulatory regions that enable expression ofa HIP or an analog or derivative thereof in an appropriate host cell.“Operably-associated” refers to an association in which the regulatoryregions and the HIP or an analog or derivative thereof to be expressedare joined and positioned in such a way as to permit transcription, andultimately, translation.

The regulatory regions that are necessary for transcription of HIP or ananalog or derivative thereof can be provided by the expression vector. Atranslation initiation codon (ATG) may also be provided if a HIP or ananalog or derivative thereof gene sequence lacking its cognateinitiation codon is to be expressed. In a compatible host-constructsystem, cellular transcriptional factors, such as RNA polymerase, willbind to the regulatory regions on the expression construct to effecttranscription of the HIP sequence in the host organism. The precisenature of the regulatory regions needed for gene expression may varyfrom host cell to host cell. Generally, a promoter is required which iscapable of binding RNA polymerase and promoting the transcription of anoperably-associated nucleic acid sequence. Such regulatory regions mayinclude those 5′ non-coding sequences involved with initiation oftranscription and translation, such as the TATA box, capping sequence,CAAT sequence, and the like. The non-coding region 3′ to the codingsequence may contain transcriptional termination regulatory sequences,such as terminators and polyadenylation sites.

In order to attach DNA sequences with regulatory functions, such aspromoters, to a HIP or an analog or derivative thereof gene sequence orto insert a HIP or an analog or derivative thereof gene sequence intothe cloning site of a vector, linkers or adapters providing theappropriate compatible restriction sites may be ligated to the ends ofthe cDNAs by techniques well known in the art (see e.g., Wu et al.,1987, Methods in Enzymol, 152:343-349). Cleavage with a restrictionenzyme can be followed by modification to create blunt ends by digestingback or filling in single-stranded DNA termini before ligation.Alternatively, a desired restriction enzyme site can be introduced intoa fragment of DNA by amplification of the DNA using PCR with primerscontaining the desired restriction enzyme site.

An expression construct comprising a HIP or an analog or derivativethereof sequence operably associated with regulatory regions can bedirectly introduced into appropriate host cells for expression andproduction of a HIP or an analog or derivative thereof without furthercloning. See, e.g., U.S. Pat. No. 5,580,859. The expression constructscan also contain DNA sequences that facilitate integration of a HIP oran analog or derivative thereof sequence into the genome of the hostcell, e.g., via homologous recombination. In this instance, it is notnecessary to employ an expression vector comprising a replication originsuitable for appropriate host cells to propagate and express HIP or ananalog or derivative thereof in the host cells.

A variety of expression vectors may be used, including but are notlimited to, plasmids, cosmids, phage, phagemids or modified viruses.Such host-expression systems represent vehicles by which the codingsequences of a HIP or an analog or derivative thereof gene may beproduced and subsequently purified, but also represent cells which may,when transformed or transfected with the appropriate nucleotide codingsequences, express HIP or an analog or derivative thereof in situ. Theseinclude, but are not limited to, microorganisms such as bacteria (e.g.,E. coli and B. subtilis) transformed with recombinant bacteriophage DNA,plasmid DNA or cosmid DNA expression vectors containing HIP or an analogor derivative thereof coding sequences; yeast (e.g., Saccharomyces,Pichia) transformed with recombinant expression vectors containing HIPor an analog or derivative thereof coding sequences; insect cell systemsinfected with recombinant virus expression vectors (e.g., baculovirus)containing HIP or an analog or derivative thereof coding sequences;plant cell systems infected with recombinant virus expression vectors(e.g., cauliflower mosaic virus, CaMV; tobacco mosaic virus, TMV) ortransformed with recombinant plasmid expression vectors (e.g., Tiplasmid) containing HIP or an analog or derivative thereof codingsequences; or mammalian cell systems (e.g., COS, CHO, BHK, 293, NS0, and3T3 cells) harboring recombinant expression constructs containingpromoters derived from the genome of mammalian cells (e.g.,metallothionein promoter) or from mammalian viruses (e.g., theadenovirus late promoter; the vaccinia virus 7.5K promoter). Preferably,bacterial cells such as Escherichia coli and eukaryotic cells are usedfor the expression of a recombinant HIP or an analog or derivativethereof. For example, mammalian cells such as Chinese hamster ovarycells (CHO) can be used with a vector bearing promoter element frommajor intermediate early gene of cytomegalovirus for effectiveexpression of a HIP or an analog or derivative thereof sequence(Foecking et al., 1986, Gene 45:101; and Cockett et al., 1990,BioTechnology 8:2).

In bacterial systems, a number of expression vectors may beadvantageously selected depending upon the use intended for the HIP oran analog or derivative thereof being expressed. For example, when alarge quantity of a HIP or an analog or derivative thereof is to beproduced, for the generation of pharmaceutical compositions of a HIP oran analog or derivative thereof, vectors that direct the expression ofhigh levels of fusion protein products that are readily purified may bedesirable. Vectors include, but are not limited to, the E. coliexpression vector pCR2.1 TOPO (Invitrogen); pIN vectors (Inouye &Inouye, 1985, Nucleic Acids Res. 13:3101-3109; Van Heeke & Schuster,1989, J. Biol. Chem. 24:5503-5509), and the like. Series of vectors likepFLAG (Sigma), pMAL (NEB), and pET (Novagen) may also be used to expressthe foreign proteins as fusion proteins with FLAG peptide, malE-, orCBD-protein. These recombinant proteins may be directed into periplasmicspace for correct folding and maturation. The fused part can be used foraffinity purification of the expressed protein. Presence of cleavagesites for specific proteases like enterokinase allows one to cleave offthe HIP or an analog or derivative thereof. The pGEX vectors may also beused to express foreign proteins as fusion proteins with glutathione5-transferase (GST). In general, such fusion proteins are soluble andcan easily be purified from lysed cells by adsorption and binding tomatrix glutathione agarose beads followed by elution in the presence offree glutathione. The pGEX vectors are designed to include thrombin orfactor Xa protease cleavage sites so that the cloned target gene productcan be released from the GST moiety.

In an insect system, many vectors to express foreign genes can be used,e.g., Autographa californica nuclear polyhedrosis virus (AcNPV) can beused as a vector to express foreign genes. The virus grows in cells likeSpodoptera frugiperda cells. A HIP or an analog or derivative thereofcoding sequence may be cloned individually into non-essential regions(e.g., the polyhedrin gene) of the virus and placed under control of anAcNPV promoter (e.g., the polyhedrin promoter).

In mammalian host cells, a number of viral-based expression systems maybe utilized. In cases where an adenovirus is used as an expressionvector, a HIP or an analog or derivative thereof coding sequence ofinterest may be ligated to an adenovirus transcriptiontranslationcontrol complex, e.g., the late promoter and tripartite leader sequence.This chimeric gene may then be inserted in the adenovirus genome by invitro or in vivo recombination. Insertion in a non-essential region ofthe viral genome (e.g., region E1 or E3) will result in a recombinantvirus that is viable and capable of expressing HIP or an analog orderivative thereof in infected hosts (see, e.g., Logan & Shenk, 1984,Proc. Natl. Acad. Sci. USA 8 1:355-359). Specific initiation signals mayalso be required for efficient translation of inserted HIP or an analogor derivative thereof coding sequences. These signals include the ATGinitiation codon and adjacent sequences. Furthermore, the initiationcodon must be in phase with the reading frame of the desired codingsequence to ensure translation of the entire insert. These exogenoustranslational control signals and initiation codons can be of a varietyof origins, both natural and synthetic. The efficiency of expression maybe enhanced by the inclusion of appropriate transcription enhancerelements, transcription terminators, and the like (see, e.g., Bittner etal., 1987, Methods in Enzymol. 153:51-544).

In addition, a host cell strain may be chosen which modulates theexpression of the inserted sequences, or modifies and processes the geneproduct in the specific fashion desired. Such modifications (e.g.,glycosylation) and processing (e.g., cleavage) of protein products canbe important for the function of the protein. Different host cells havecharacteristic and specific mechanisms for the post-translationalprocessing and modification of proteins and gene products. Appropriatecell lines or host systems can be chosen to ensure the correctmodification and processing of the foreign protein expressed. To thisend, eukaryotic host cells that possess the cellular machinery forproper processing of the primary transcript and post-translationalmodification of the gene product, e.g., glycosylation andphosphorylation of the gene product, may be used. Such mammalian hostcells include, but are not limited to, PC12, CHO, VERY, BHK, HeLa, COS,MDCK, 293, 3T3, W138, BT483, Hs578T, HTB2, BT2O and T47D, NS0 (a murinemyeloma cell line that does not endogenously produce any immunoglobulinchains), CRL7O3O, and HsS78Bst cells. Expression in a bacterial or yeastsystem can be used if post-translational modifications are found to benon-essential for a desired activity of HIP or an analog or derivativethereof.

For long-term, high-yield production of properly processed HIP or ananalog or derivative thereof, stable expression in cells is preferred.Cell lines that stably express HIP or an analog or derivative thereofmay be engineered by using a vector that contains a selectable marker.By way of example but not limitation, following the introduction of theexpression constructs, engineered cells may be allowed to grow for 1-2days in an enriched media, and then are switched to a selective media.The selectable marker in the expression construct confers resistance tothe selection and may, depending on the vector construct and host cellemployed, allow cells to stably integrate the expression construct intotheir chromosomes and to grow in culture and to be expanded into celllines. Such cells can be cultured for a long period of time while HIP oran analog or derivative thereof is expressed continuously.

A number of selection systems may be used, including but not limited to,antibiotic resistance (markers like Neo, which confers resistance togeneticine, or G-418 (Wu and Wu, 1991, Biotherapy 3:87-95; Tolstoshev,1993, Ann. Rev. Pharmacol. Toxicol. 32:573-596; Mulligan, 1993, Science260:926-932; and Morgan and Anderson, 1993, Ann. Rev. Biochem. 62:191-217; May, 1993, TIB TECH 11(5):155-215); Zeo, for resistance toZeocin; and Bsd, for resistance to blasticidin); antimetaboliteresistance (markers like Dhfr, which confers resistance to methotrexate,Wigler et al., 1980, Natl. Acad. Sci. USA 77:357; and O'Hare et al.,1981, Proc. Natl. Acad. Sci. USA 78:1527); gpt, which confers resistanceto mycophenolic acid (Mulligan & Berg, 1981, Proc. Natl. Acad. Sci. USA78:2072); and hygro, which confers resistance to hygromycin (Santerre etal., 1984, Gene 30:147). In addition, mutant cell lines including, butnot limited to, tk-, hgprt- or aprt-cells, can be used in combinationwith vectors bearing the corresponding genes for thymidine kinase,hypoxanthine, guanine- or adenine phosphoribosyl-transferase. Methodscommonly known in the art of recombinant DNA technology may be routinelyapplied to select the desired recombinant clone, and such methods aredescribed, for example, in Ausubel et al. (eds.), Current Protocols inMolecular Biology, John Wiley & Sons, NY (1993); Kriegler, Gene Transferand Expression, A Laboratory Manual, Stockton Press, NY (1990); Chapters12 and 13, Dracopoli et al. (eds), of Current Protocols in HumanGenetics, John Wiley & Sons, NY (1994); and Colberre-Garapin et al.,1981, J. Mol. Biol. 150:1.

The recombinant cells may be cultured under standard conditions oftemperature, incubation time, optical density and media composition.However, conditions for growth of recombinant cells may be differentfrom those for expression of HIP or an analog or derivative thereof.Modified culture conditions and media may also be used to enhanceproduction of HIP or an analog or derivative thereof. Any techniquesknown in the art may be applied to establish the optimal conditions forproducing HIP or an analog or derivative thereof.

An alternative to producing HIP or a fragment thereof by recombinanttechniques or purification from natural sources is peptide synthesis.For example, an entire HIP or an analog or derivative thereof, or aprotein corresponding to a portion of HIP or an analog or derivativethereof, can be synthesized by use of a peptide synthesizer.Conventional peptide synthesis or other synthetic protocols well knownin the art may be used.

Proteins having the amino acid sequence of HIP or an analog orderivative thereof or a portion thereof may be synthesized bysolid-phase peptide synthesis using procedures similar to thosedescribed by Merrifield, 1963, J. Am. Chem. Soc., 85:2149. Duringsynthesis, N-α-protected amino acids having protected side chains areadded stepwise to a growing polypeptide chain linked by its C-terminaland to an insoluble polymeric support, i.e., polystyrene beads. Theproteins are synthesized by linking an amino group of an N-α-deprotectedamino acid to an α-carboxyl group of an N-α-protected amino acid thathas been activated by reacting it with a reagent such asdicyclohexylcarbodiimide. The attachment of a free amino group to theactivated carboxyl leads to peptide bond formation. The most commonlyused N-α-protecting groups include Boc, which is acid labile, and Fmoc,which is base labile. Details of appropriate chemistries, resins,protecting groups, protected amino acids and reagents are well known inthe art and so are not discussed in detail herein (See, Atherton et al.,1989, Solid Phase Peptide Synthesis: A Practical Approach, IRL Press,and Bodanszky, 1993, Peptide Chemistry, A Practical Textbook, 2nd Ed.,Springer-Verlag).

Purification of the resulting HIP or an analog or derivative thereof isaccomplished using conventional procedures, such as preparative HPLCusing gel permeation, partition andor ion exchange chromatography. Thechoice of appropriate matrices and buffers are well known in the art andso are not described in detail herein.

With the foregoing detailed description of the reagents and methods ofthe invention, the following Examples are provided to illustrate variousaspects of the invention.

Example 1 HIPs Cause an Increase in Insulin Production In Vitro in HumanPancreatic Ductal Tissue Culture and Human Islet Tissue Cultures

Human pancreatic islet and progenitor fractions were cultured over 10days, according to standard protocol. Briefly, pancreata from adulthuman cadaveric organ donors were obtained through the local organprocurement organization. Islets were isolated according to establishedprotocols described by Bonner-Weir and Jamal. (Bonner-Weir et al.,Pediatric Diabetes:2004; 5(Suppl 2):16-22. Jamal et al., Cell DeathDiffer. 2005 July; 12(7):702-12).

Following removal of the organ, cold ischemia time was no more than 8hours prior to islet isolation. The main pancreatic duct was cannulatedand perfused with Liberase HI (Roche Diagnostics). The perfused organwas placed in a closed system (Ricordi Apparatus) and heated to 37° C.to activate the enzyme blend. Following the appearance of free islets insamples, the system was cooled and free tissues were collected andwashed. Tissues were applied to a continuous density gradient createdusing Ficoll (Biochrom KG) in a cell processor (COBE). Free islets withdiameters ranging from 75 to 400 μm, determined to be greater than 90%pure by staining with dithizone (Sigma) a zinc chelater, were collectedand washed. IHC to detect the presence of amylase and cytokeratin wasnegative, consistent with the absence of progenitor and exocrine tissue.The progenitor fraction from this separation was also collected forculture.

Isolated islets were embedded in a type 1 collagen matrix at a densityof 2000 islet equivalents25 cm² and cultured in DMEMF12 containing 10%FBS, 1 μM dexamethasone, 10 ngml EGF, 24 mUml insulin and 100 ngmlcholera toxin. Medium was changed every other day. On day 10, culturewas continued in the above medium, without the cholera toxin, withneogenic agents and inhibitors at the final concentrations listed below.Medium was changed every other day. Collagen-embedded cultures wereharvested by incubating with 0.25 gL collagenase XI (Sigma) for 30minutes at 37° C.

After culture the human pancreatic islet and progenitor fractions werethen treated in a blinded study with one of three HIPs: SEQ ID NOs: 7, 3or 2, the hamster INGAP sequence as a positive control (IGLHDPSHGTLPNGS(SEQ ID NO:27)) or a scrambled peptide sequence that was synthesized byBachem BioScience (95% pure, research grade) (DGGTPQPGNWIELTH (SEQ IDNO:28)). Duplicate cultures were treated on Day 10 and Day 12 and thenlysed for detection of insulin content on day 14. During 10 day culture,the insulin production decreases to negligible amounts and, aftertreatment with peptides, insulin is produced again.

Insulin levels were detected by Radioimmunoassay (RIA) from culturestreated with saline only, scrambled peptide, SEQ ID NOs: 7, 3 or 2 andhamster INGAP. The results for human ductal tissue fraction are shown inFIG. 1, and for human islet tissue in FIG. 2. Both fractions containprogenitor cells which are the nidus for new islet structures and uponwhich HIP exerts its stimulatory effect. FIG. 3 shows the ductal tissueculture fraction after HIP treatment, just before lysis and measurementby RIA. Morphological changes show islet like structure. Consistently weobserve greater induction of new islets from the cells cultured from theductal fraction of the pancreatic tissue. This observation is consistentwith the notion that fewer progenitor cells are among the islet tissuefraction after the isolation process.

Example 2 HIP Induces Insulin Production In Vitro in Hud 270 Cells

Human pancreatic tissue was treated as described in Example 1 andInsulin production was measured by ELISA assay. FIGS. 4 and 5 show theresults of this experiment to show a dose response and to again comparethe effect of HIP on the two different fractions of tissue as comparedto the hamster INGAP sequence and a scrambled negative peptide sequence.Lanes 1-3 shows results from Hud 270 cells human ductal cells isolatedas described in Example 1, treated with HIP with the sequences of SEQ IDNOs:7, 3 and 2, respectively. Lane 4 shows cells treated with a peptidewith the INGAP sequence (SEQ ID NO:27). Lane 5 shows cells treated witha scrambled peptide (SEQ ID NO:28). The results in FIG. 4 involve theuse of 5 μg of each peptide, while the results in FIG. 5 were acquiredusing 0.002 μg of each peptide. FIG. 7A shows results for cells culturedfrom the islet fraction and treated with 3 μM and 1 mM of each peptide,while FIG. 7B shows results for cells cultured from the ductal fractionand treated with 3 μM and 1 mM of each peptide.

Each of the HIP peptide sequences induced insulin production moreeffectively than INGAP or scrambled peptide, and the higherconcentration of peptide produced a more profound effect in ductalcultures in which progenitor cells are more concentrated. In the isletcultures, the limiting factor for the degree to which the cultures areable to produce more insulin is not the concentration of the peptide,but the number of progenitor cells per culture.

Example 3 HIP Induces Islet Generation in Human Ductal Tissue Culture

A human ductal tissue fraction was isolated and cultured as described inExample 1. After 10 days of culture, cells were treated with HIP forfour days and observed using inverted microscopy. FIGS. 3A, 3B, and 3Cshow cultures treated with HIP sequences, and FIG. 3D shows the negativecontrol ductal tissue treated with no peptide. FIG. 6A shows humanpancreatic progenitor tissue cultures at day 12 (day 2 of treatment withHIP). Islets have formed what has previously been described as ductalepithelial cysts and are starting to bud at one end where a progenitorcell resides. FIG. 7B shows human pancreatic progenitor tissue culturesat day 18 (day 6 of treatment with HIP). In this figure the darkening ofthe budding portion of the ductal epithelial cyst indicates thedifferentiation of cells consistent with previously shown changes thatoccur with hamster INGAP treatment in vitro.

Example 4 Clinical Trial Protocol for HIP

In this example, qualified animal models for diabetes are employed toexamine the dose ranges of HIP.

Treatment with HIP

Animal Model.

The non-obese diabetic (NOD) mouse strain has long been studied as anexcellent model of type 1 diabetes because it spontaneously develops adisease that is very similar to the human condition. Delovitch, T. L.,and Singh, B. 1997. Immunity. 7:727-738. Diabetes in NOD mice ismediated by inflammatory autoreactive T cells that recognize pancreaticislet antigens and escape central and peripheral tolerance.

Procedure:

In a parental colony of NOD mice, incidence of diabetes in female NODmice is typically 75-90% by 30 weeks but may exceed 90% in some cohorts.Each mouse receives dosages of HIP and is compared to NOD mice who doesnot receive HIP. Doses of HIP range from 1 μgkgday to 100 mgkgday.

Treatment.

Cohorts are treated in 2 arms with 2-4 dose ranges of HIP and a placebo,at a compensated dose for animal size, metabolism and circulation, orabout ⅙ the mgkg equivalence. Arm 1: saline, Arm 2: HIP.

Study Assessment.

Blood glucose levels are measured every week with a One Touch II glucosemeter (Lifescan). Mice are considered diabetic after 2 consecutivemeasurements over 300 mgdl. For histological analysis, pancreases aresnap-frozen. Multiple 5-μm sections are stained with hematoxylin andeosin and scored blindly for severity of insulitis as known in the art.

Results.

NOD mice taking HIP display a pronounced reduction in blood glucoselevels and decreased showing of insulinitis in their pancreases.

Example 5 Clinical Trial Protocol to Examine Effects of HIP on HumanNon-Endocrine Pancreatic Epithelial Cells

A total of 48 adult NOD-scid mice will be used as recipients fortransplants of tissue isolated from human pancreatic donor organs. Twocohorts will defined by the type of human tissue transplanted into themice I) Nonendocrine ductal tissue and II) control nonpancreatic tissue.

Treatment of with HIP Peptides

A total of 24 animals from each cohort will be randomized into one of 4study groups for a total intervention of 39 days of twice dailyintraperitoneal (IP) injections:

HIP Derivatives (250 μg100 μl twice daily for a total of 500 μgday)

Blinded HIP A peptide SEQ ID NO:7 (n=6)

Blinded HIP B peptide SEQ ID NO:3 (n=6)

Blinded HIP C peptide SEQ ID NO:2 (n=6)

Saline injected twice daily at an equivalent volume (100 μl) (n=6)

Blood glucose will be determined every three (3) days at the same timeof day in all study animals. All animals will be killed on day 48 byexsanguination, and the transplant grafts will be will be excised formorphologic analysis.

Peptide Preparation

Each vial contains 1500 μg of lyophilized HIP or analogues orderivatives thereof. Under sterile conditions, 600 μl isotonic salinewill be added to each vial, providing six 100 μl IP sterile injectionsper vial for each study animal per group, one per animal each treatmenttime.

Glucose Measurements

Plasma glucose measurements will be made on each animal in all studygroups every three (3) days at the same time of day. Glucose levels overtime will be evaluated for all study groups.

Human C-Peptide and Insulin Measurements

Plasma and pancreatic insulin will be measured via a solid-phaseradioimmunoassay. The collected blood will be centrifuged and the plasmafrozen at −70° C. until assayed for insulin. A portion of each excisedtransplant will be weighed and then subjected to an overnightacid-ethanol extraction at 4° C. The cell-free extracts will becollected, neutralized with 0.4 M Tris base, and stored at −70° C. untilbeing assayed for human C-peptide and insulin. Determinations will beperformed in triplicate.

Microscopy and Morphometric Analysis

On excision of human tissue, each will be weighed and then fixed inparaformaldehyde. Embedded samples will be stained and evaluated for

-   -   a) islet numbermm²,    -   b) beta cell massmg tissue weight,    -   c) duct associated and extra-islet acinar-associated beta cell        mass, and    -   d) percentage of PDX-1 immunopositive duct cells.

Tissue will be probed with primary antibodies directed against humanC-peptide, human insulin, human glucagon, human somatostatin and humanpancreatic polypeptide.

Example 6 Clinical Trial Protocol for HIP and GLP-1 or GLP-1 ReceptorAgonist, GLP-1 Analog

In this example, qualified animal models for diabetes are employed toexamine the dose ranges of synergistic interaction of HIP and agents forstimulating pancreatic islet cell regeneration.

Treatment with HIP and GLP-1 or GLP-1 Receptor Agonist or GLP-1 Analog

Animal Model.

The non-obese diabetic (NOD) mouse strain has long been studied as anexcellent model of type 1 diabetes because it spontaneously develops adisease that is very similar to the human condition. Delovitch, T. L.,and Singh, B. 1997. Immunity. 7:727-738. Diabetes in NOD mice ismediated by inflammatory autoreactive T cells that recognize pancreaticislet antigens and escape central and peripheral tolerance.

Procedure:

In a parental colony of NOD mice, incidence of diabetes in female NODmice is typically 75-90% by 30 weeks but may exceed 90% in some cohorts.Each mouse receives dosages of HIP andor amylin and is compared to NODmice that receive neither. Doses of HIP range from 1 ngkgday to 100mgkgday. Doses of amylin range from 0.3-0.8 ngkgday.

Treatment.

Cohorts are treated in 4 arms with 2-4 dose ranges of each drug and aplacebo, at a compensated dose for animal size, metabolism andcirculation, or about ⅙ the mgkg equivalence. Arm 1: saline, Arm 2: HIP;Arm 3: amylin; Arm 4: HIP plus amylin.

Study Assessment.

Blood glucose levels are measured every week with a One Touch II glucosemeter (Lifescan). Mice are considered diabetic after 2 consecutivemeasurements over 300 mgdl. For histological analysis, pancreases aresnap-frozen. Multiple 5-μm sections are stained with hematoxylin andeosin and scored blindly for severity of insulitis as known in the art.

Results.

NOD mice taking HIP display a pronounced reduction in blood glucoselevels and decreased showing of insulinitis in their pancreases.

Example 7 Clinical Trial Protocol for HIP, AmylinSYMLIN™ and DIAPEP277™in Patients with Preexisting Type 1 Diabetes

In this example for the human clinical trial, the 5 step method to beutilized among type 1 patients is outlined utilizing HIP, SYMLIN™ andDIAPEP277™. The five step methods for treatment of type 1 diabetes withHIP andor HIP analogs includes the following steps: 1) IntensiveGlycemic Management, 2) Achievement and maintenance of25-hyrdroxyvitamin D levels to >40 ngdl via oral cholecalciferol(Vitamin D3) 3) Immune Therapy, 4) HIP administration and Insulintapering followed by discontinuation of both HIP and Insulin and 5)Immune modulation protocol with DiaPep277 at the end of month 2 of theintensification of glucose, and at the onset up usage of HIP and at 6months following the initiation of HIP (Raz et al., Lancet. 2001:24;358(9295):1749-53) and as necessary based upon C-peptide and GADantibody titers.

Qualified patients with type 1 diabetes will be selected for study andall patients will receive 3 months of intensification of their diabeteswith multiple insulin injections, insulin pump usage andor addition ofSYMLIN™ prior to meals with an appropriate reduction in pre-mealinsulin. During this period of intensive glucose management, allpatients will have their 25-hydroxyvitamin D measured, and thosepatients with values less than 40 ngml will have 1000 or 2000 IU VitaminD3 (cholecalciferol) added to their treatment regiment.

Half of the patients will be randomized to the intervention group orplacebo group. The placebo group will receive one placebovehiclesubcutaneous injection at the end of month two of intensification ofglucose vs. those in the intervention trial, who will receive asubcutaneous injection of 1 mg of subcutaneous DIAPEP277™ (Raz et al.,Lancet. 2001:24; 358(9295):1749-53). Patients will be seen weekly andmodifications made in their diabetes regimen.

At the end of three months of intensification, patients in both groupswill continue to have 25-hydroxy vitamin D levels measured andmaintenance of Vitamin D3 as necessary to ensure levels above 40 ngml.Those patients in the intervention arm, will receive anothersubcutaneous injection of DIAPEP277™, while the placebo arm will receivea placebovehicle injection. Those patients on insulin and SYMLIN™ orinsulin alone, who are randomized to HIP therapy, dosed at a total of800-900 mgday (average dosage of 10 mgkgday in 4 divided dosages) givenin subcutaneous injections prior to each meal and at bedtime. Those inthe placebo group will take 4 injections of an inert vehicle beforemeals and at bedtime.

All patients will be monitored closely, with glucose levels, C-peptideand stimulated C-peptide levels. Insulin and SYMLIN™ will be titrated asnecessary to maintain goal glucose levels of 80-110 mgdL fasting and110-140 mgdL two hours post-prandially. Within 3-6 months, it isexpected that the intervention group may be completely tapered offinsulin. At the end of 6 months following the initial administration HIPor placebo therapy, a final injection of DIAPEP277™ or placebo will begiven to protect new islets in the intervention group.

Example 8 Clinical Trial Protocol for HIP, AmylinSYMLIN™ and DIAPEP277™in Patients with New Onset Type 1 Diabetes

In this example for the human clinical trial, methods to be utilizedamong type 1 patients is outlined utilizing HIP, SYMLIN™ and DIAPEP277™.The methods for treatment of type 1 diabetes with HIP andor HIP analogsincludes the following steps: 1) Immediate randomization to interventionor control group followed by administration of DIAPEP277™ subcutaneouslyvs. placebo among control patients 2) Achievement and maintainence of25-hyrdroxyvitamin D levels to >40 ngdl via oral cholecalciferol(Vitamin D3) 3) One month intensive management with Insulin and SYMLIN™4) HIP administration and Insulin tapering followed by discontinuationof both HIP and Insulin and 5) Immune modulation protocol with DiaPep277at one month following the initial injection then again at 6 months (Razet al., Lancet. 2001:24; 358(9295):1749-53) and as necessary based uponC-peptide and GAD antibody titers.

Qualified patients with new onset type 1 diabetes will be selected forstudy and all patients will receive either placebo or DIAPEP277™followed by 1 months of intensification of their diabetes with multipleinsulin injections, insulin pump usage andor addition of SYMLIN™ priorto meals with an appropriate reduction in premeal insulin. During thisperiod of intensive glucose management, all patients will have their25-hydroxyvitamin D measured, and those patients with values less than40 ngml will have 1000 or 2000 IU Vitamin D3 (cholecalciferol) added totheir treatment regiment.

At the end of one months of intensification, patients in both groupswill continue to have 25-hydroxy vitamin D levels measured andmaintenance of Vitamin D3 as necessary to ensure levels above 40 ngml.Those patients in the intervention arm, will receive anothersubcutaneous injection of DIAPEP277™, while the placebo arm will receivea placebovehicle injection. Those patients on insulin and SYMLIN™ orinsulin alone, who are randomized to HIP therapy, dosed at a total of800-900 mgday (average dosage of 10 mgkgday in 4 divided dosages) givenin subcutaneous injections prior to each meal and at bedtime. Those inthe placebo group will take 4 injections of an inert vehicle beforemeals and at bedtime.

All patients will be monitored closely, with glucose levels, C-peptideand stimulated C-peptide levels. Insulin and SYMLIN™ will be titrated asnecessary to maintain goal glucose levels of 80-110 mgdL fasting and110-140 mgdL two hours post-prandially. Within 3-6 months, it isexpected that the intervention group may be completely tapered offinsulin. At the end of 6 months following the initial administration HIPor placebo therapy, a final injection of DIAPEP277™ or placebo will begiven to protect new islets in the intervention group.

Animal Model.

The non-obese diabetic (NOD) mouse strain has long been studied as anexcellent model of type 1 diabetes because it spontaneously develops adisease that is very similar to the human condition. Delovitch, T. L.,and Singh, B. 1997. Immunity. 7:727-738. Diabetes in NOD mice ismediated by inflammatory autoreactive T cells that recognize pancreaticislet antigens and escape central and peripheral tolerance.

Procedure:

In a parental colony of NOD mice, incidence of diabetes in female NODmice is typically 75-90% by 30 weeks but may exceed 90% in some cohorts.Each mouse receives dosages of HIP andor amylin andor DIAPEP277™ and iscompared to each other and NOD mice who receive nothing. Doses of HIPrange from 1 mgkgday to 100 mgkgday. Doses of amylin range from 0.3-0.8μgkgday. Doses of DIAPEP277™ range from about 0.1-0.2 mg 1 week beforethe administration of HIP or amylin.

Treatment.

Cohorts are treated in 6 arms with 2-4 dose ranges of each drug and aplacebo, at a compensated dose for animal size, metabolism andcirculation, or about ⅙ the mgkg equivalence. Arm 1: saline, Arm 2: HIP;Arm 3: amylin; Arm 4: HIP plus amylin; Arm 5 HIP plus DIAPEP277™; Arm 6HIP plus amylin plus DIAPEP277™.

Study Assessment.

Blood glucose levels are measured every week with a One Touch II glucosemeter (Lifescan). Mice are considered diabetic after 2 consecutivemeasurements over 300 mgdl. For histological analysis, pancreases aresnap-frozen. Multiple 5-μm sections are stained with hematoxylin andeosin and scored blindly for severity of insulitis as known in the art.

Results.

NOD mice taking HIP display a pronounced reduction in blood glucoselevels and decreased showing of insulinitis in their pancreases.

Although the present invention has been described in detail withreference to specific embodiments, those of skill in the art willrecognize that modifications and improvements are within the scope andspirit of the invention, as set forth in the claims which follow. Allpublications and patent documents (patents, published patentapplications, and unpublished patent applications) cited herein areincorporated herein by reference as if each such publication or documentwas specifically and individually indicated to be incorporated herein byreference. Citation of publications and patent documents is not intendedas an admission that any such document is pertinent prior art, nor doesit constitute any admission as to the contents or date of the same. Theinvention having now been described by way of written description andexample, those of skill in the art will recognize that the invention canbe practiced in a variety of embodiments and that the foregoingdescription and examples are for purposes of illustration and notlimitation of the following claims.

We claim:
 1. A method of treating a pathology associated with impairedpancreatic function in a subject in need thereof comprising:administering to the subject a therapeutically effective amount of ahuman proislet peptide comprising an amino acid sequence of WIGLHDP (SEQID NO: 6).
 2. The method of claim 1, wherein the pathology is selectedfrom pre-diabetes, type 2 diabetes, latent autoimmune diabetes, andhyperglycemia.
 3. The method of claim 1 further comprising the step ofadministering one or more agents for stimulating pancreatic islet cellregeneration.
 4. The method of claim 3, wherein the agent forstimulating pancreatic islet cell regeneration is selected from a memberof the group consisting of human proislet peptide, amylin, pramlinitide,exendin-4, liraglutide, GLP-1 receptor agonists, GLP-1, hamster INGAP,GIP, dipeptydyl peptidase-4 inhibitors and analogs thereof.
 5. Themethod of claim 1 further comprising the step of administering one ormore agents that inhibit autoimmune cells that target pancreatic isletcells.
 6. The method of claim 5, wherein the agent that inhibits theautoimmune cells that target pancreatic islet cells is selected from thegroup consisting of anti-CD3 antibody, rapamycin, FK506, heat-shockprotein, tacrolimus, GAD65 vaccine, mycophenolate mofetil, lysofylline,rituximab, daclizumab, anti-CD52 antibody, anti-CD20 antibody, VitaminD, IBC-VSO vaccine, interferon alpha and CD4+CD25+ antigen-specificregulatory T cells.
 7. The method of claim 6, wherein the vitamin D isvitamin D3.
 8. The method of claim 7, wherein the vitamin D3 isadministered to the subject in an amount effective to maintain25-hydroxy vitamin D above about 40 ngmL in the subject.
 9. The methodof claim 1, wherein at least one symptom of the pathology associatedwith impaired pancreatic function is treated as a result of theadministration of at least one human proislet peptide.
 10. The method ofclaim 9, wherein the symptom is selected from a member of the groupconsisting of frequent urination, excessive thirst, extreme hunger,unusual weight loss, increased fatigue, irritability, blurry vision,genital itching, odd aches and pains, dry mouth, dry or itchy skin,impotence, vaginal yeast infections, poor healing of cuts and scrapes,excessive or unusual infections, hyperglycemia, loss of glycemiccontrol, fluctuations in postprandial blood glucose, fluctuations inblood glucagons and fluctuations in blood triglycerides.
 11. The methodof claim 1, wherein the subject is a mammal.
 12. The method of claim 11,wherein the mammal is selected from a human, a horse, a cow, a sheep, adog and a cat.
 13. The method of claim 1, wherein the peptide consistsessentially of SEQ ID NO:
 6. 14. The method of claim 1, wherein thepeptide comprises a chemically modified peptide comprising SEQ ID NO: 6.15. The method of claim 1, wherein the peptide is a fusion peptidecomprising SEQ ID NO:
 6. 16. The method of claim 1, wherein the peptideis administered in a pharmaceutical composition.
 17. The method of claim1, wherein the peptide is administered to said subject by a routeselected from orally, subcutaneously, transdermally, intranasally,parenterally, topically and buccally.
 18. The method of claim 1 furthercomprising administering insulin.
 19. The method of claim 1, whereinsaid human proislet peptide is conjugated to a compound selected fromalbumin, transferrin and polyethylene glycol.